Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care.  You asked the Plan to pay for acute inpatient hospital care. You say that you had a kidney transplant, and you need continuous transplant care. The Plan denied your request. The Plan says based on Medicare guidelines, the service(s) you and/or your provider are requesting do not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole.
You asked the Plan to pre-approve Omeprazole. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole.
Benefits for Omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.
You asked the Plan to pre-approve Xarelto. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.
Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).
You asked the Plan to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that the member has failed non-operative treatment and the evidence supports this procedure as primary treatment for chronic low back pain. You say that this procedure is medically necessary and the most effective treatment at this time. The Plan denied your request. The Plan says experimental and investigational devices are not covered.
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 spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). 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 spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit 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 that your request for a vitamin infusion is not a covered benefit. Additionally, the requested provider is not a participating provider within the Plan's 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. Additionally, your request for an office visit for a vitamin infusion is not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.  You asked the Plan to pre-approve the Superion device. 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 Superion 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 Superion spacer is experimental. More research is needed to show safety and efficacy of this 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 Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that the enrollee has been on Eliquis since 2019. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.     Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron.  You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.     Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve GeneSight testing.  You asked the Plan to pre-approve GeneSight testing. 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 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 GeneSight testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a diagnosis of Major Depressive Disorder Recurrent, Moderate with Anxious Distress. There is no documentation of a PHQ-9 as you have only taken Zoloft 25 mg daily. There is no documentation that you are not responding to at least one other medication which is noted in the record as well as being on multiple medications for your condition which increase the risk of adverse effects as noted again. The ordering psychiatrist must be board certified in psychiatry or neuropsychiatry. Therefore, you do not meet criteria for the requested 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 GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pre-approve GeneSight testing.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zilretta.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee pain and osteoarthritis. There is no imaging confirmation for a diagnosis of osteoarthritis as the etiology of the left knee pain. The records do not support that Zilretta is reasonable and medically necessary and safe and effective 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special anesthesia services provided on December 18, 2020, billed with code 99100.  You asked the Plan to pay for the services as billed. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says the anesthesia services were paid, but payment for 99100 is bundled and not made separately.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is bundled in payment for other services. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on December 18, 2020, billed with code 99100.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet nerve blocks (64493, 64494).  You asked the Plan to pre-approve facet nerve blocks. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary when after the first diagnostic facet joint procedure there was a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used).  We looked at the file and Medicare rules. The records indicate that the enrollee received a facet nerve block in June, but the results of this procedure are not documented. Based on this information, we decided that Medicare rules for coverage of facet nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet nerve blocks (64493, 64494).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve a partial lower denture (D5214). You say that your dentist advised you to get a partial lower denture because you are missing teeth. You also say that chewing food makes your gums hurt. The Plan denied your request. The Plan says partial lower denture 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 partial denture requires prior authorization. The record shows that there were no medical records or x-ray provided that indicate the requested service is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system.
You asked the Plan to pre-approve power seat elevation system. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have
to pre-approve power seat elevation system
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) provided on August 6, 2021.  You asked the Plan to pay for the trimming of dystrophic nails. You say that you would like reconsideration because the rendered services were medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the routine foot care.  The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit unless you have diabetic foot disease or some other condition that makes professional care of your feet medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pay for the trimming of dystrophic nails. Our reviewer says that the progress note does not mention the necessary risk factors that would allow for routine foot care including CPT code G0127. The member is not noted to have a systemic disease such as a metabolic, neurologic, or peripheral vascular disease of sufficient severity that performance of such foot care services by a nonprofessional would put the member at risk. There is no noted severe circulatory embarrassment of the lower extremities or desensitization of the member's legs or feet.. Our physician reviewer found the above criteria is necessary in order for coverage of routine foot care. The medical documentation does not support that this member requires routine foot care performed by a professional such as a podiatrist.. Therefore, we decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a benefit exception for 6 maintenance chiropractic visits.  You asked the Plan to pre-approve the chiropractic visits. You say that you have multiple sclerosis that flares up and the chiropractic services help relieve the pain. The Plan denied your request. The Plan says the diagnosis codes the provider is using is not specific to multiple sclerosis and maintenance services are not covered  The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve a benefit exception for 6 maintenance chiropractic visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chondroplasty services (29887).  You asked the Plan to pre-approve chondroplasty services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure would be considered a duplicate request to what has been approved.  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 chondroplasty services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Plan has approved the requested code 29881 (meniscectomy). The additional code of 29887 is not supported as would be considered a duplicative request. The noted code 29887 (chondroplasty) is included with the already approved code of 29881 and is not a separate billable procedure when performed on the same knee. Major mechanical issues are not consistently evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for knee surgery services chondroplasty, (CPT 29887) 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 chondroplasty services have not been met. Therefore, we decided that the Plan does not have to pre-approve chondroplasty services (29887).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala.
You asked the Plan to pre-approve Nucala. You say that the enrollee's symptoms are well controlled when he is
consistent with Nucala therapy. The Plan denied your request. The Plan says this drug is not covered under the
medical benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Nucala.
Benefits for Nucala may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).  You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has failed months of conservative treatment. You say that this treatment is considered safe and effective, and the procedure should be pre-authorized. The Plan denied your request. The Plan says the services 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 pre-approve the insertion of stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Interspinous process stabilization devices remain 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 insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies to be provided by an out-of-network provider.  You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network care have not been met.  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 continuous glucose monitor and related supplies to be provided by an out-of-network provider.