Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve15 fractions of IMRT with IGRT. You asked the Plan to pre-approve15 fractions of IMRT with IGRT. You say that the requested 15 fractions of IMRT with IGRT is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for 15 fractions of IMRT with IGRT.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 15 fractions of IMRT with IGRT. Our reviewer says that the enrollee does not meet criteria for 15 fractions of IMRT with IGRT. Our physician reviewer found IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. There is a role of IMRT in reducing normal lung, cord, and esophageal dose, although generally is considered necessary on a case to case basis for advanced lung cancer. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure.With IMRT, often full dose can be delivered to the target, while minimizing dose to the normal organs.  IMRT can be considered necessary when a 3D plan is unacceptable and the IMRT plan results in a clinically meaningful reduction in normal tissue dose-volume delivery and/or improved target coverage.This enrollee has node negative disease, and therefore these study results do not apply as the lung exposure would be expected to be relatively low, particularly with an apical lung lesion. There is no documentation that the lesion is near or abutting the spinal cord, esophagus, brachial plexus or heart or that a non-IMRT plan would exceed tolerance of these tissues/organs. Without a dosimetric comparison, the need for IMRT is not justified. Even in the absence of a dosimetric comparison, there is no plausible rationale for the need for IMRT provided.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 fractions of IMRT with IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approve15 fractions of IMRT with IGRT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020) and sales tax (S9999) purchased December 1, 2020.
You asked the Plan to pay for the vision services. You say that this service should be reimbursed by the plan. The Plan denied your request. The Plan says the claim was processed and the plan paid for one pair of eyeglasses. The second pair exceeds the annual benefit limitation per the Evidence of Coverage. Sales tax is not covered under Medicare
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the plan covers one pair of eyeglasses (lenses and frames) every year. We looked at the file and the Plan's rules. The plan covers only one pair of eyeglasses (lenses and frames) every year. The plan covered for one pair of eyeglasses. The second pair of eyeglasses and sales tax is not
covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020) and sales tax (S9999) purchased December 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the duplex scan provided on February 19, 2020.You asked the Plan to waive the deductible for the duplex scan. You say that you were never told that you would have to check that the provider was in-network.The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is an $800 deductible that applies towards duplex scans. The duplex scan you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible that applies towards duplex scans. This cost sharing is a contractual obligation that had not been met at the time the duplex scan was received on February 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the duplex scan provided on February 19, 2020. Please note, your other appeal inquiry will be handled separately.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a history of heart disease, stroke, chronic kidney disease, hypertension, and COVID-19, who was hospitalized with severe sepsis secondary to a urinary tract infection. It is documented that the enrollee has multiple partial thickness pressure wounds. On 3/19/21 the enrollee had normal vital signs. The hemoglobin was stable. Oral vancomycin was being administered for Clostridia difficile. The enrollee's condition was noted to be "poor, prognosis guarded." Based on the documentation provided, the enrollee does not require skilled nursing on a daily basis. Physical therapy and occupational therapy are to be continued. However, the enrollee does not require skilled therapy on a daily basis. The documentation does not support that skilled therapy services are necessary on a daily basis in an inpatient setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
You asked the Plan to pre-approve this service. You say that this service is medically necessary to treat lumbar spinal stenosis. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. Open laminectomy is the gold standard for spinal stenosis decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish, two first intraoral
periapical x-rays, two problem focused limited oral evaluations, periodic oral evaluation, bitewings, and
prophylaxis provided from June 9, 2020, to August 19, 2020, by an OON provider.
You asked the Plan to pay for the topical application of fluoride varnish, first intraoral periapical x-rays,
problem focused limited oral evaluations, periodic oral evaluation, bitewings, and prophylaxis. You say that
you believe that these services should be covered at the in-network rates. The Plan denied your request. The
Plan says topical application of fluoride varnish is not a covered benefit. The Plan also says that the claims for
the first intraoral periapical x-rays, problem focused limited oral evaluations, periodic oral evaluation,
bitewings, and prophylaxis processed correctly because they were rendered by an OON provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, topical application of fluoride varnish
is not among those covered under this benefit. The contract clearly states that you are responsible for a 20%
coinsurance for each covered diagnostic and preventive service when they are received OON. You are also
responsible for the difference between the billed amount and allowed amount for services that are received
OON. The record also shows that the Plan confirmed that this provider's contract with the Plan termed and they
were no longer participating with the Plan at the specific location that the services were rendered at as of
January 1, 2020. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride
varnish, two first intraoral periapical x-rays, two problem focused limited oral evaluations, periodic oral
evaluation, bitewings, and prophylaxis provided from June 9, 2020, to August 19, 2020, by an OON provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel One.
You asked the Plan to pre-approve Gel One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that you do not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel One. Our reviewer says that the documentation supports that the requested drug meets step therapy criteria. Our physician reviewer found you have right knee pain and osteoarthritis confirmed by imaging who failed multiple treatment scenarios per the providers documentation. You have had two Gel-One injections in the past (the last approximately 9 months ago) with relief of pain. The Plan requires a trial of Euflexxa, Supartz Fx, Durolane, or Gelsyn-3 before they will approve the requested drug. Trial and failure of the required drug(s) (step therapy) may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. In this case, you have had two Gel-One injections in the past (the last approximately nine months ago) with relief of pain. The requested Gel-One is medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel One have been met. Therefore, we decided that the Plan has to pre-approve Gel One.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 19, 2020.You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 19, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found it is not medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". The enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 23, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, each additional intraoral periapical x-ray, and first intraoral periapical x-ray provided on July 9, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, each additional intraoral periapical x-ray, and first intraoral periapical x-ray. You say that you would like these services to be covered. The Plan denied your request. The Plan says benefits for the comprehensive oral evaluation and additional intraoral periapical x-ray have been satisfied and the frequency limitations have been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on October 6, 2020, and your comprehensive oral evaluation benefit has been exhausted. The contract also lists intraoral x-rays as a covered benefit and is limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on July 9, 2020, and your intraoral x-rays benefit had been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, each additional intraoral periapical x-ray, and first intraoral periapical x-ray provided on July 9, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray and sacral spine x-ray rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 71045 and 72220 were billed incorrectly.

The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities.

We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. The application of the -TC modifier to codes 71045 and 72220 is not valid. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray and sacral spine x-ray rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the titanium crowns provided on September 21, 2020.
You asked the Plan to pay for the titanium crowns. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the titanium crowns provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not meet the criteria for an inpatient rehabilitation stay which requires intensive rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure with acute respiratory failure. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.