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

We decided that the Plan does not have to pre-approve Gammunex infusions (J1561).
You asked the Plan to pre-approve the Gammunex infusions. You say that when you called to schedule this month's appointment you were advised that your insurance denied the procedure. You also say that you do not
understand what is happening because this procedure was done last month. The Plan denied your request. The Plan says the information provided did not meet Medicare rules. The Plan also says that it appears that you are doing well with the Gammagard infusions so far.
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 the Gammunex infusions. Our reviewer says that Gammunex infusions are not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of drug Gammagard infusions before they will approve the requested drug. In this case, you have not tried and failed the required drug. Our reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 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 Gammunex infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammunex infusions (J1561).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoes and diabetic inserts to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the diabetic shoes and diabetic inserts. You say that there is no in-network provider that can supply the shoes. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the diabetic shoes and diabetic inserts to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0480) rendered by the out-of-network (OON) provider on June 4, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0480) rendered by the out-of-network (OON) provider on June 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records sent by the doctor do not show treatment for any of the required conditions.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence-based indication for a spinal cord stimulator noted in the records. This request is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9945), provided on April 5, 2021.
You asked the Plan to pay for the occlusal guard. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.
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. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9945), provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, 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 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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found E2300 does not serve a primarily medical purpose, and is not medically necessary. In terms of E2311, E2313, and E2377, the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices. (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed herself supports that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, K0108) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital admission and services.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are still having symptoms and working through changes in your medication. The Plan denied your request. The Plan says the services you need can be safely received in a setting such as a partial hospitalization program or intensive outpatient treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care. Our reviewer says that the health plan's denial of inpatient psychiatric services appears appropriate in this case. Our physician reviewer found you were admitted to the acute inpatient psychiatric hospitalization on November 1, 2021 with Major Depressed Disorder, Single Episode, Unspecified. Based upon review the records provided it was not expected that you would improve in a reasonable period of time as you did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any aggressive behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you did not meet the criteria for acute inpatient mental health treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology and the cytopathology services provided on April 19, 2021.
You asked the Plan to pay for the surgical pathology and the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 pay for the surgical pathology and the cytopathology services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed Barrett's esophagus. Esophagogastroduodenoscopy with biopsy was performed. WATS 3D biopsy, a computer-assisted evaluation of biopsy sample was requested. This test was not supported by the documentation or current evidence to suggest it would lead to improved outcomes for the enrollee tested. The enrollee had already known Barrett's with visible improvement from Esophagogastroduodenoscopy which is sufficient information to decide the treatment plan for this enrollee. Therefore, the enrollee did not have a diagnosis/condition that met criteria for the services rendered. 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 surgical pathology and the cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology and the cytopathology services provided on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the StabiLink MIS spinal fixation system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the use of this product during spinal surgery is better than standard allograft products
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this system is experimental, and more research is needed at this time. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the StabiLink MIS spinal fixation system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 2, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 2, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from November 2, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 2, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 2, 2021, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 2, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 2, 2021, forward.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Zephyr Valve Insertion.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that there is lack of documentation of pulmonary rehabilitation or any documentation for contraindication or inability to participate in a comprehensive pulmonary rehab program.
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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. You have severe chronic obstructive pulmonary disease (COPD) with air trapping and meet clinical criteria for the procedure in terms of pulmonary function testing and 6-minute walk distance. You have not undergone pulmonary rehabilitation, but that has not been routinely available because of the pandemic, so that requirement should be waived. Endobronchial valves (EBV) has been shown in sham-controlled clinical trials to provide benefits comparable with lung reduction surgery in patients with COPD and severe air trapping. Our physician reviewer found that your condition meets criteria for coverage of 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 been met. Therefore, we decided that the Plan has to pre-approve Zephyr Valve Insertion.
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 a semi-electric hospital bed (E0261) and dry pressure mattress (E0184).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate that there is a requirement for frequent and immediate changes in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 services. Our reviewer says that the requested bed and mattress are not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you. There is no evidence in the documentation that you completely immobile. There is no evidence you have limited mobility and cannot make changes in body position significant enough to alleviate pressure, or that you have any stage pressure ulcer on the trunk or pelvis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261) and dry pressure mattress (E0184).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic cholecystectomy to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a laparoscopic cholecystectomy to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid check (92593), provided on April 27, 2021.
You asked the Plan to pay for a hearing aid check. You say that the service should be covered. The Plan denied your request. The Plan says you have exhausted your Plan's benefit for this service.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aid check once per a plan year. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid check (92593), provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) 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 the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices. (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed herself supports that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.