Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral knee orthoses.
You asked the Plan to pre-approve the requested orthoses. The Plan denied your request. The Plan says there has not been a recent injury or surgical procedure on the knee.
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 orthoses. Our physician reviewer found that the enrollee has bilateral knee osteoarthritis and chronic knee pain. He is being treated with Zilretta injections bilaterally and has failed conservative measures. He walks with a limp. There is no evidence of laxity or instability on a physical exam of the knees. There is no evidence of a recent surgery or injury to the knee. The enrollee is noted to be ambulatory, but there is no evidence he requires the requested knee orthosis.
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 orthoses have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral knee orthoses
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prostate specific antigen blood test to be completed with code 84999.
You asked the Plan to pre-approve the prostate specific antigen blood test to be completed with code 84999. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested code is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
Review of the file shows that the test at issue in this appeal is being requested with code 84999. Code 84999 is identified as an unlisted chemistry procedure. This means the requested code of 84999 is being requested solely for screening purposes. Medicare does not cover tests solely for screening purposes. There is a more appropriate code to be used for the requested prostate specific antigen blood test. The Plan has made note that the requested test would be approved if the appropriate code was being requested. Therefore, we decided that the Plan does not have to pre-approve the prostate specific antigen blood test to be completed with code 84999.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
 
 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has tried and failed the Plan's required drug, zoledronic acid. The 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. Therefore, the reviewer found that the Plan's 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 Prolia have not been met. Specifically, the file does not show that the enrollee 
has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia 
(J0897)
Appeal type: Practitioner Services
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 reasonable and necessary. The Plan denied your request. The Plan says the requested Intracept 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 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. More research is needed to show safety and efficacy. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination of Ontruzant and Paclitaxel.
You asked the Plan to pre-approve Ontruzant and Paclitaxel. You say that it is incorrect that no previous
treatment has been done. The Plan denied your request. The Plan says the denial of authorization for this drug
combination is correct, because the enrollee has not received previous treatment for esophageal and
esophagogastric junction cancer.
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 Ontruzant and Paclitaxel. Our reviewer
says that the enrollee does not meet the criteria for the requested combination of Ontruzant and Paclitaxel. Our
physician reviewer found this combination is not Food & Drug Administration (FDA) approved for the
enrollee's diagnosis. This combination is not supported by one of the major drug compendia or by clinical
research appearing in a Medicare-approved medical journal. The enrollee has progressed on prior trastuzumab
regimens.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ontruzant and Paclitaxel have not been met. Therefore, we decided that the Plan
does not have to pre-approve a combination of Ontruzant and Paclitaxel.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abdominal lipectomy/panniculectomy.
You asked the Plan to pre-approve abdominal lipectomy/panniculectomy. You say that you get sores, infections, and rashes. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that you have had stable weight for at least 6 months, a panniculus that hangs below the level of the symphysis pubic, or that conservative treatment has been undertaken.
The Plan follows Medicare rules. Medicare rules state that abdominal lipectomy/panniculectomy may be covered under certain conditions following significant weight loss.
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 abdominal lipectomy/panniculectomy. Our reviewer says that you do not meet the Medicare criteria for this abdominal lipectomy/panniculectomy. Our physician reviewer found the record indicates that you have had significant weight loss this year. Your weight loss plateaued as of October 2021 but the record does not show that you have had a stable weight for at least 6 months. Therefore, the requested service is not recommended 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 abdominal lipectomy/panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve abdominal lipectomy/panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a screening CT colonography (74263).
You asked the Plan to pre-approve a screening CT colonography. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is not a Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that screening CT colonography is not covered. We looked at the file and Medicare rules. The request is for a screening CT colonography. Based on this information, we decided that Medicare rules for coverage of a screening CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve a screening CT colonography (74263).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the blood collection through an implantable device provided on March 1, 2021, and June 1, 2021.

You asked the Plan to waive the copayments for the blood collection through an implantable device. You say that you did not receive any outpatient surgery services on these days. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $100 copayment for the blood collection through an implantable device on each date of service. The record shows you were charged code 36591 which is considered a surgical procedure. The blood collection through an implantable device falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the blood collection through an implantable device provided on March 1, 2021, and June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel testing.

You asked the Plan to pre-approve the testing services. You say that your doctor needs this test. The Plan
denied your request. The Plan says the requested 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 looked at the file, and Medicare rules. The requested testing is unlikely to impact therapeutic decision-making
in your clinical management Based on this information, we decided that Medicare rules for coverage of
the testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve
targeted genomic sequence analysis panel testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that SBRT is only covered for certain 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 stereotactic body radiation therapy (SBRT). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has lung and bladder neck cancer with metastases to the cervical vertebra. The records provided do not describe why other radiation therapy measures are not appropriate or safe for the particular enrollee. The elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the requested SBRT. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stereotactic body radiation therapy (SBRT) have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.

You asked the Plan to pre-approve continued SNF care. You say that the continued SNF care as requested is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for continued SNF care have 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service nor skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6245) and retainer crowns (D6740).
You asked the Plan to pre-approve the pontic (D6245) and retainer crowns (D6740). You say that you had a bridge 26 years ago and now you are in pain. You say that you have no teeth on the left side and need the issue fixed. The Plan denied your request. The Plan says the services are not covered benefits.
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 the pontic (D6245) and retainer crowns (D6740).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 stab
incisions and stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions identified with codes
37765 and 37766.
You asked the Plan to pre-approve stab phlebectomy. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that stab phlebectomy is covered for certain 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 stab phlebectomy. Our reviewer says
that the documentation does support that the requested services are medically reasonable and necessary. Our
physician reviewer found the documentation shows that the bilateral stab phlebectomies that were denied due
to absence of documentation of perforator reflux. However, the indications for stab phlebectomy of venous
tributaries is not dependent on the reflux status of perforator veins. There is satisfactory documentation of
significant varicosities that would be amenable to stab phlebectomy at the time of possible endovenous
ablation. As the Plan has already determined that varicose vein treatment on both legs is indeed medically
necessary, the addition of stab phlebectomy at the same time is reasonable. Therefore, the enrollee meets
criteria for the requested stab phlebectomy 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 stab phlebectomy have been met. Therefore, we decided that the Plan has to
pre-approve stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions and stab phlebectomy of
varicose veins, 1 extremity; more than 20 incisions identified with codes 37765 and 37766.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit and the debridement provided on April 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the physician visit and the debridement. You say that the services were 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 records provided for review do not show that the services at issue were urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the physician visit and the debridement provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for MRI provided on April 29, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford the copayment. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for in-network diagnostic radiology (CT, MRI, PET scan, etc.).
You have been asked to pay a $100 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve open sacroiliac (SI) joint fusion.
You asked the Plan to pre-approve open SI joint fusion. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 open SI joint fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria is not met. The enrollee has had extensive degenrative lumbar spine surgery. There is no SI joint instability, fracture, or lesion. SI joint fusion not 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 open SI joint fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve open sacroiliac (SI) joint fusion
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15.

You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan denied your request. The Plan says core build up is not a covered dental 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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional trips for routine transportation.

You asked the Plan to pre-approve 30 additional trips. You say that you only need an additional 10 to 18 trips. You say that you have to see a doctor every 4 weeks and pick up prescriptions from the pharmacy. You say that you were advised by a representative that extra trips would be granted. You also say that you have received a denial for the extra trips. The Plan denied your request. The Plan says up to 60 one-way trips are covered per calendar year. The Plan says you have 4 remaining trips for the calendar year. The Plan also says that additional trips are not covered.

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 60 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. Therefore, we decided that the Plan does not have to pre-approve 30 additional trips for routine transportation.