Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient wound care provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient wound care. You say that the service is medically necessary and prior authorization is not required. The Plan denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the outpatient wound care provided on January 29, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy services coded 52441 and 52442 provided on January 18, 2021.
You asked the Plan to pay for the cystourethroscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes 52441 and 52442 are not supported in the medical record. Specifically, these codes do not appear on Addendum AA for covered surgical procedures including surgical procedures for which payment is packaged. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy services coded 52441 and 52442 provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22873).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary.
The Plan denied your request. The Plan says this is 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 insertion of a Vertiflex device. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the Food and Drug Administration (FDA)-approved indications for the Vertiflex
device include implantation of the device at one or two adjacent lumbar levels in patients with moderate spinal
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has
multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including
the planned level of implantation L2-3 and L3-4).

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 insertion of a Vertiflex device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22873).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the service or procedure is helpful for treatment of your health problem.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for back pain. More research is needed.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the enrollee was referred by a non-contracted provider, Therefore, we decided that the Plan does not have to pay for the drug testing provided on December 8, 2020 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).

You asked the Plan to pre-approve Aranesp. You say that the request for Aranesp is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Retacrit, for at least 2 consecutive months with appropriate dose adjustment.

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 Aranesp. Our reviewer says that Aranesp is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Retacrit. The reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Aranesp, is not medically reasonable and necessary as the step therapy criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Specifically, the file shows that the enrollee has not tried and failed the Plan's required drug. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.

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 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 skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extensive removal of extra skin and tissue of
abdomen (15847).
You asked the Plan to pre-approve the extensive removal of extra skin and tissue of abdomen. You say that you
would like hospital expenses for the associated surgery covered. The Plan denied your request. The Plan says
because this is not a covered service, all associated costs will not be covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
We looked at the file and Medicare rules. In this case, you agree that this is cosmetic surgery but would like the
hospital costs covered. However, because this is not a covered surgery all costs must be paid out-of-pocket.
Based on this information, we decided that Medicare rules for coverage of the extensive removal of extra skin
and tissue of abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve the
extensive removal of extra skin and tissue of abdomen (15847).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee is appropriate for rehab placement. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 the enrollee's condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 additional trips for routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you need to see your primary care physician (PCP), neurologist, and neurosurgeon. You say that the neuropathy in your leg is progressing. You say that there are no real taxi services. You also say that you have no one else that can drive you. The Plan denied your request. The Plan says 52 one-way trips are covered per calendar year. The Plan says that the additional one-way trips you have requested would exceed your benefit limit for the current calendar year. The Plan also says there are no further benefits available for the requested additional trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The file shows that the Plan has paid for 18 of the 22 trips allowed for dental and vision appointments, and 42 of the 30 trips allowed for standard routine medical services, thus the transportation benefit has been exhausted. 18+42=60. Therefore, we decided that the Plan does not have to pre-approve 20 additional trips for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the apnea monitor (A4556), provided on February 26, 2021.
You asked the Plan to pay for the apnea monitor. You say that the item should be covered. The Plan denied your request. The Plan says the item was used in a hospital and not a home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the apnea monitor was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the apnea monitor (A4556), provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you just had foot surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.
You asked the Plan to pre-approve Venofer. You say that this drug is medically necessary to treat the enrollee's
condition. The Plan denied your request. The Plan says the requested drug is not medically reasonable and
necessary for the enrollee's condition as there is no evidence of iron deficiency anemia.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Venofer. Our reviewer says that the
drug is not medically necessary and reasonable. Our physician reviewer found intravenous iron such as
Venofer is indicated for repletion of iron for iron deficiency anemia. In this case, the enrollee has an iron
saturation of 38% and a ferritin of 925 with a hemoglobin of 11.7. Therefore, the requested drug is not
medically necessary 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 Venofer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Venofer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal.
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1800 units of Dysport every 12 weeks.
You asked the Plan to pre-approve 1800 units of Dysport every 12 weeks.. You say that the enrollee's dose has been gradually increasing and working well. The Plan denied your request. The Plan says the requested dosage is not supported.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 1800 units of Dysport every 12 weeks.. Our reviewer says that the requested dosage of Dysport is not supported. Our physician reviewer found where dose modification is necessary for the treatment of cervical dystonia, uncontrolled open-label studies suggest that dose adjustment can be made in 250 Unit steps according to the individual patient's response, with re-treatment every 12 weeks or longer, as necessary, based on return of clinical symptoms. Uncontrolled open-label studies also suggest that the total dose administered in a single treatment should be between 250 Units and 1000 Units. Doses above 1000 Units have not been systematically evaluated. The documentation does not support that the requested dosage of Dysport is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1800 units of Dysport every 12 weeks. have not been met. Therefore, we decided that the Plan does not have to pre-approve 1800 units of Dysport every 12 weeks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care provided on April 1, 2021.
You asked the Plan to pay for the services provided. You say that payment is warranted. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided does not show the services were billed with an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the hospital care provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX procedure to treat reflux symptoms.
You asked the Plan to pre-approve the LINX procedure. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 LINX procedure. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you are a 67-year-old female with bladder cancer, fibromyalgia, pancreatic
insufficiency, and osteoarthritis. In this case, you have been diagnosed with gastroesophageal reflux disease
(GERD) with laryngopharyngeal reflux (LPR) symptoms, but there is limited correlation of reflux events with
reported symptoms. It is not medically necessary nor appropriate to subject you to the procedural risks of LINX
for surgical augmentation of what appears to be a normal-functioning lower esophageal sphincter (LES).
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 LINX procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LINX procedure to treat reflux symptoms.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322).

You asked the Plan to pre-approve Hymovis. You say that the enrollee has been experiencing knee pay for 4 months. You say that the enrollee has completed 2 months of physical therapy and medication therapy with little to no help. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred alternative drugs, Euflexxa, Durolane, Supartz-FX, and Gelsyn-3.

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 Hymovis. Our reviewer says that Hymovis is not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee has trialed viscosupplemental treatments such as Euflexxa, Durolane, Supartz-FX, and Gelsyn-3. The reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Therefore, without the support of the documentation, the reviewer found that Hymovis is not medically reasonable or necessary, as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Specifically, the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on December 23, 2020 by an OON provider.
You asked the Plan to pay for the endodontic therapy. You say that you were out of state and needed to have an emergency dental procedure. You also say that you found a dentist that accepted your insurance. The Plan denied your request. The Plan says services rendered by a dentist who does not participate with your plan is not a covered benefit under your 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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on December 23, 2020 by an OON provider.