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

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee's pain is disabling, affects their quality of life daily and has been of long-term duration. You state given that the enrollee had failed non-operative treatment, you feel that their only solution is the intracept procedure. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 of the procedure.
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 (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre system.
You asked the Plan to pre-approve the Freestyle Libre system. You say that your long-term high blood sugar treatment is changing substantially from metformin, Actos and glimepiride to metformin and Ozempic together with a very low carbohydrate diet and fasting to try and improve insulin insensitivity. You state that during this transition, you are trying to ensure you do not drop into hypoglycemia. You state this meter is critical to getting you off all these medications. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cardiovascular treadmill stress test (code 93015), the technetium tetrodosmin injection (code A9502), and the regadenoson injection (code J2785) you had on May 12, 2021, on the same date as myocardial perfusion imaging.
You asked the Plan to waive the cost sharing for the treadmill stress test, the technetium tetrodosmin injection, and the regadenoson injection. You say that all of these services were part of your procedure, so there should not be separate cost sharing for each. You do not appear to be appealing the $200 copayment for the myocardial perfusion imaging itself. The Plan denied your request. The Plan says you were charged these cost sharing amounts correctly. The Plan also says that for the treadmill stress test, the allowed amount for this service ($62.59) is less than your copayment obligation, so you are responsible for the full allowed amount for that service.
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 treadmill stress tests and 20% coinsurance for Medicare Part B drugs. This includes drugs that aren't usually self-administered by the patient and are injected or infused while you are getting physician, hospital, or surgical services. You have been asked to pay a $100 copayment for the treadmill stress test, and 20% coinsurance for the technetium tetrodosmin injection and the regadenoson injection. Both the technetium tetrodosmin injection and the regadenoson injection are considered Medicare Part B drugs. The $200 copayment for the myocardial perfusion imaging just covers the imaging service itself. These other related items and services have separate and different cost sharing amounts. 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 cost sharing for the cardiovascular treadmill stress test (code 93015), the technetium tetrodosmin injection (code A9502), and the regadenoson injection (code J2785) you had on May 12, 2021, on the same date as myocardial perfusion imaging.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Carboplatin, Atezolizumab, Paclitaxel, and Bevacizumab.
You asked the Plan to pre-approve treatment with Carboplatin, Atezolizumab, Paclitaxel, and Bevacizumab. You say that this is medically necessary. The Plan denied your request. The Plan says this is medically necessary.
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 treatment with Carboplatin, Atezolizumab, Paclitaxel, and Bevacizumab. Our reviewer says that the requested use of these drugs is not supported. Our physician reviewer found this regimen is recommended as first line therapy when the patient's programmed death-ligand 1 (PDL1) is greater than 1%. This patient has had prior therapy and his PDL1 is 0.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment with Carboplatin, Atezolizumab, Paclitaxel, and Bevacizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Carboplatin, Atezolizumab, Paclitaxel, and Bevacizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient care from November 6, 2021, forward.
You asked the Plan to pre-approve inpatient care from November 6, 2021, forward. You say that the services are medically necessary. 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 inpatient care from November 6, 2021, forward. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation the enrollee was clinically stable and care could safely be given in alternate 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 inpatient care from November 6, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient care from November 6, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare or the Plan.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that these services are medically reasonable and necessary. The Plan denied your request. The Plan says the requested 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3310) for tooth #'s 8 and 9 and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
You asked the Plan to pre-approve the endodontic therapies and intravenous moderate (conscious) sedation/analgesia. You say that the root canals should be approved before you get your crowns. The Plan denied your request. The Plan says these services are not 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy (D3310) for tooth #'s 8 and 9 and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation (T2003) to and from your doctor's office.
You asked the Plan to pre-approve the transportation service. You say that you have trouble walking. You say it is a long way to your doctor's office. You say that there are no taxis or public transportation available. You also say that you need this service in order to seek proper medical attention. The Plan denied your request. The Plan says non-emergency transportation to your doctor's office for a scheduled appointment is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation (T2003) to and from your doctor's office.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery. You asked the Plan to pre-approve the Vertiflex surgery. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says there is insufficient evidence of efficacy of the requested procedure. 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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939).
You asked the Plan to pre-approve the bone marrow aspirate. You say that this procedure is medically
reasonable and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of
bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated at this point.
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 bone marrow aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the requested bone aspirate is not supported in the peer reviewed literature at this
point. Therefore, the request is considered 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 bone marrow aspirate have not been met. Therefore, we decided that the
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth # 8 and 9.
You asked the Plan to pre-approve the dental services. You say that you are not able to eat properly as you do not have your front teeth. You say that this has been going on since September. You also say that you cannot go anywhere without front teeth. The Plan denied your request. The Plan says crowns are covered once every 60 months per tooth, per patient. The Plan says that the frequency limit has been reached. The Plan also says that you received crowns on teeth # 8 and 9 on October 29, 2018, less than 60 months ago.
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 and crowns are listed as covered services, the frequency limit has been reached. Therefore, we decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth # 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant (CPT code 81240) and F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant (CPT code 81241), for the enrollee.
You asked the Plan to pre-approve the genetic testing. You say that it is an urgent request due to mutation. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The rules say that genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. Therefore, we decided that the Plan does not have to pre-approve F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant (CPT code 81240) and F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant (CPT code 81241), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care facility. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that the amount of strength required and the frequency of the change in height requires that the enrollee have a total electric bed. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a total electric hospital bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair of a patient-owned oxygen regulator.
You asked the Plan to pre-approve the repair of a patient-owned oxygen regulator. You say that this is medically necessary to fix malfunctioning equipment. The Plan denied your request. The Plan says this item does not qualify for coverage according to Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that accessories used with beneficiary-owned oxygen equipment will be denied as non-covered. We looked at the file and Medicare rules. The rules indicate that this accessory is owned by the enrollee and is not eligible for payment according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repair of a patient-owned oxygen regulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the repair of a patient-owned oxygen regulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Yervoy in combination with Opdivo.
You asked the Plan to pre-approve Yervoy. You say that the enrollee has cancer and will respond to this
medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because studies have not proven that the requested use of Yervoy is helpful for the enrollee's condition.
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 Yervoy. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Yervoy. Our physician reviewer found
Yervoy is not Food & Drug Administration (FDA) approved for the requested use. There is no major drug
compendia or Medicare-approved clinical research support for the requested use of Yervoy in combination
with Opdivo.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Yervoy in combination with Opdivo.