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

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. 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 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 a Vertiflex procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Food and Drug Administration states that the requested procedure is
indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs
secondary to a diagnosis of moderate lumbar spinal stenosis, and that the requested procedure is
contraindicated if the individual has morbid obesity, defined as a body mass index of greater than 40. The
record indicates that the enrollee demonstrates less than moderate central and foraminal stenosis at L4-L5, the
level requested for treatment. The record indicates that the enrollee is obese but no current body mass index is
provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion office visit with a specialist to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a second opinion office visit with a specialist. You say that you specifically requested a consult/second opinion with a gastrointestinal oncologist because this specialist can address your current, specific medical challenges and to the best of your knowledge, the Plan does not have a gastrointestinal oncologist. You also say that you requested this specific provider because it is a well-known institution of research and teaching, and it is your hope that a gastrointestinal oncologist at this location can clarify some of the unknowns of your current medical condition and possibly provide you with additional treatment options. The Plan denied your request. The Plan says there are some specialists that are in-network that you can see. The Plan also says that it is not necessary to refer you to out-of-network because your illness is managed on a multi-disciplinary level and the Plan has gastroenterology oncologists in its network that can provide you with a second opinion and a treatment plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion office visit with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MTHFR genetic testing.
You asked the Plan to pre-approve MTHFR genetic testing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this testing is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that MTHFR genetic testing is considered investigational and is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MTHFR genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve MTHFR genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you moved, so this should be covered. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 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 the office visit provided on September 1, 2021, by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prednisolone acetate eye drop.
You asked the Plan to pre-approve Prednisolone acetate. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered
drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Prednisolone
acetate eye drop.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that you have trouble traveling to see a doctor and the doctor assigned to you is not a family doctor. The Plan denied your request. The Plan says this is available in-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. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 additional routine trips.
You asked the Plan to pre-approve additional routine transportation. You say that you currently have no form of transportation. You also say that it is important that you keep your medical appointments. The Plan denied your request. The Plan says additional trips that exceed the transportation benefit 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 20 additional routine trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy (D3320), a surgical implant (D6010), a custom fabricated abutment (D6057), and a crown (D6058) to be provided by a participating provider.  You asked the Plan to pre-approve endodontic therapy, a surgical implant, a custom fabricated abutment, and a crown. You say that you would like approval for these services. The Plan denied your request. The Plan says the requested dental 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 endodontic therapy (D3320), a surgical implant (D6010), a custom fabricated abutment (D6057), and a crown (D6058) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve extractions (D7140) for teeth # 24 and 25, a partial upper denture (D5213), a partial lower denture (D5214), and scaling and root planing (D4341) for all 4 quadrants.  You asked the Plan to pre-approve the dental services. You say that you would like these services to be covered under your insurance. The Plan denied your request. The Plan says you are not enrolled in the optional supplemental dental coverage. The Plan also says the requested dental services are not listed as covered.  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 extractions, partial dentures, and scaling and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extractions (D7140) for teeth # 24 and 25, a partial upper denture (D5213), a partial lower denture (D5214), and scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the implantation of an auricular stimulator (64555, L8679).  You asked the Plan to pre-approve the implantation of an auricular stimulator. You say that this is a covered service. The Plan denied your request. The Plan says this is experimental.  The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.     We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an implanted nerve stimulator because the device involve needles inserted around the nerves and not electrodes being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of an auricular stimulator (64555, L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture treatment.
You asked the Plan to pre-approve the acupuncture. You say that you believe that acupuncture is your next option of treatment. It does not require any medication and has been recommended by your provider. The Plan denied your request. The Plan says acupuncture is only covered for the treatment of low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you do not have chronic lower back pain and is seeking acupuncture treatment for generalized pain related to fibromyalgia and osteoarthritis. Therefore, we decided that the Plan does not have to pre-approve the acupuncture treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual swingaway hardware (E1028).
You asked the Plan to pre-approve manual swingaway hardware. You say that this is medically necessary. The
Plan denied your request. The Plan says this is included in an approved item.
The Plan must follow Medicare rules. Medicare rules say that E1028 is not used in addition to E1020 (Residual
limb support system) as it includes swingaway hardware.
We looked at the file and Medicare rules. The item as issue is included in the residual limb support system that
was approved by the plan. It cannot be approved as a separate item. Based on this information, we decided that
Medicare rules for coverage of manual swingaway hardware have not been met. Therefore, we decided that the
Plan does not have to pre-approve manual swingaway hardware (E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 acupuncture visits (97810).  You asked the Plan to pre-approve the acupuncture visits. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does not show 12 or more weeks of chronic back pain. Therefore, we decided that the Plan does not have to pre-approve 12 acupuncture visits (97810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup (D2950) to be provided by a participating provider.  You asked the Plan to pre-approve a core buildup. You say that you would like approval for this dental work. The Plan denied your request. The Plan says the requested dental service is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony, with unusual surgical complications (D7241) and immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221).  You asked the Plan to pre-approve removal of an impacted tooth and an immediate upper partial denture. You say that this description is not correct. The Plan denied your request. The Plan says these services are not covered under your 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 removal of impacted tooth - completely bony, with unusual surgical complications (D7241) and immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (D5221).   Please note, if you believe the pre-approval has been submitted with an incorrect billing code, you may wish to have the appeal re-submitted to the Plan with a corrected code for review.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).   You asked the Plan to pre-approve the dental item. You say that the enrollee has no teeth. You say that the enrollee can only chew food with their denture. You also say that the requested denture is medically necessary. The Plan denied your request. The Plan says partial upper denture with flexible base is not listed as 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 denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the Life2000 System is not medically necessary.  This system is not a true ventilator because it is not capable of providing full ventilatory support.  It is meant to be used with activity rather than during sleep.  There is inadequate evidence of efficacy in any lung disease.  In addition, the enrollee does not meet Medicare criteria for a home ventilator.  The enrollee has severe chronic obstructive pulmonary disease (COPD), but there are no arterial blood gases (ABG) done when stable and outpatient showing CO2 retention.  Medicare does not cover a home ventilator when used as BiPAP.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing (procedure code 81271) for the enrollee.  You asked the Plan to pre-approve the testing. You say that the etiology of the cholera is unclear. The Plan denied your request. The Plan says this testing is unlikely to impact therapeutic decision-making in the clinical management of the enrollee and will be denied automatically as not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that rules say that CPT 81271 is unlikely to impact therapeutic decision-making in the clinical management of the patient.  The requested testing is coded as CPT 81271. Medicare does not consider this testing to be medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (procedure code 81271) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an alternative switchbox (K0108) for a power wheelchair.  You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this should not be requested separately.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature, and is already included in the payment for E2377. It cannot be covered separately. Therefore, we decided that the Plan does not have to pre-approve an alternative switchbox (K0108) for a power wheelchair.