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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there appears to be some concerns that the devices are not as effective as surgical
decompression and lead to higher rates of reoperation.

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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed showing safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a second opinion. You say that you would like a second opinion. The Plan denied your request. The Plan says there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this service is considered experimental.
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 the Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services (S9122).
You asked the Plan to pre-approve home health aide services. You say that you need help following surgery. The Plan denied your request. The Plan says you do not have skilled needs.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found although you recently underwent gallbladder surgery, there is no evidence that you need home health skilled nursing or therapy services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services (S9122).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins
when required (D2950).
You asked the Plan to pre-approve the crown and core buildup. The Plan denied your request. The Plan says
these services are not covered under the enrollee's benefit plan.
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 pre-approve a
crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your
request. The Plan says this use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda. Our reviewer says that the
requested use of Keytruda is not supported. Our physician reviewer found Keytruda is FDA approved as a
single-agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression. Patients with
EGFR or ALK genomic tumor aberrations should have disease progression prior to receiving pembrolizumab.
There is no PD-L1, EGFR, or ALK testing 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda (J9271).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the plan has no contractual obligation to cover services that are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability. Proton therapy is not investigational- it is simply a different means to deliver radiation. Based on the provided records, it is plausible that this case represents an exceptional case for which proton therapy is necessary. Treating this disease with IMRT, based on the size and location of the disease, and the need to escalate the dose (as sarcomas require higher doses than other cancer types) would be limited with either relatively poor target coverage or excessive exposure of normal tissues. As such, proton therapy would be "Furnished in accordance with accepted standards of medical practice."

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and needs to become totally independent. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 admission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFAs.

You asked the Plan to pre-approve destruction by neurolytic agent (64635, 64636). You say that the enrollee is suffering and needs radio frequency ablation. The Plan denied your request. The Plan says the enrollee has had epidural steroid injections which have not provided significant relief. The enrollee has had prior RFA of the facet joints, last one in 2017. The enrollee underwent diagnostic MBBs and there was no significant pain relief. The clinical information provided does not show the enrollee meets criteria for the spinal injection.

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 destruction by neurolytic agent (64635, 64636). Our reviewer says that the request is considered not medically reasonable or necessary. Our physician reviewer found the request does not meet the criteria of the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent (64635, 64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve RFAs.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve low back injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the enrollee has not had two medial branch blocks.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.

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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain. He has had physical therapy and is doing a home exercise program. He takes Hydrophone-Acetaminophen for pain. He had an epidural steroid injection with 55-60% pain relief. He also had a set of diagnostic medial branch blocks (MBBs) and achieved 80% pain relief. The request is for a second set of MBBs. The enrollee achieved 80% pain relief; therefore, the request is deemed medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve low back injections.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a heavy-duty manual wheelchair.

You asked the Plan to pre-approve the continued rental. You say that this is medically necessary. The Plan denied your request. The Plan says this can be approved for thirty days while the current wheelchair is repaired.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a power operated vehicle already. This serves the same purpose as the requested wheelchair. The requested wheelchair rental cannot be approved for longer than a month, as the current wheelchair should be repaired by then. Therefore, we decided that the Plan does not have to pre-approve continued rental of a heavy-duty manual wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee no longer requires daily skilled services and the continuation of SNF services is not medically necessary.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third opinion for neurosurgery services.
You asked the Plan to pre-approve a third opinion. The Plan denied your request. The Plan says a third opinion 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 a third opinion. Our physician reviewer found that you have low back pain and a history of T12-L1 fusion. You wish to remove the instrumentation in your back. Two neurosurgeon consultations had been completed suggesting not to remove anything. There was no differing opinion of the first two consultants. There was insufficient support made for a third opinion. The wish was for a GPS device be removed from his back, but there was no evidence of such a device present. Therefore, this request for a third neurosurgeon opinion will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a third opinion have not been met. Therefore, we decided that the Plan does not have to pre-approve a third opinion for neurosurgery services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Monovisc (J7327).
You asked the Plan to pre-approve Monovisc. You say that the requested drug is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for Monovisc have not been met.
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 Monovisc. Our reviewer says that
treatment with the requested drug is not medically reasonable and necessary. Our physician reviewer found that
the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The Plan requires a trial of drugs
Visco-3, Gel-One, Orthovisc, and Synvisc before they will approve the requested drug. The enrollee has not
tried and failed the required drugs. The documentation does not support that Visco-3, Gel-One, Orthovisc, or
Synvisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Monovisc (J7327).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the coflex device.
You asked the Plan to pre-approve these services. You say that this is needed for spinal stabilization. The Plan denied your request. The Plan says that severe facet hypertrophy that requires extensive bone removal would cause spinal instability which is a contraindication for this device.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The coflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that your condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this device 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's quality of life has been compromised. The Plan denied your request. The Plan says published studies do not demonstrate any long-term health outcome advantages.
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 the requested services. Our physician reviewer found that interspinous spacer devices remain experimental. More research is needed to show its safety and efficacy. Therefore, the requested device is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.