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

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the requested treatment is
considered safe and effective. You say that it is supported by its clinical benefits, continued medical
professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your
request. The Plan says the requested device is unproven and is not medically necessary 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 a Vertiflex Superion device. Our
reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this
case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for
this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception to guidelines.
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 Superion device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral medial branch blocks.
You asked the Plan to pre-approve bilateral medial branch blocks. You say that you have degenerative disc disease and ambulates with a walker. You say that you cannot sleep due to constant back pain. The Plan denied your request. The Plan says the requested injection services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who have no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.
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 bilateral medial branch blocks. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain related to vertebral compression fractures, postural kyphosis and spinal stenosis. Our physician reviewer found that there is documentation indicating that there is non-facet pathology. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick catheter device.
You asked the Plan to pre-approve the requested item. You say that you are scared to go to the bathroom at night. The Plan denied your request. The Plan says you are not confined to a bed or immobile.
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 item. Our physician reviewer found that you have mild stress incontinence. A pubovaginal sling was recommended but you chose acupuncture. Treatment with anticholinergics was not effective. There is no history of urinary tract infections or sacral ulcers, and you are not confined to bed. Urodynamics revealed mild stress incontinence but there is no detrusor instability. The requested PureWick device at issue in this is not case medically reasonable and necessary. There is no evidence to show the PureWick system to be an effective alternative in managing stress urinary incontinence.
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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a PureWick catheter device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer, with compressor (E0570) provided March 3, 2021.
You asked the Plan to pay for the nebulizer, with compressor. You say that you were in New York for a week in March. You had to go to the hospital where they treated you. You were discharged past midnight and was given a prescription for a nebulizer machine. The Plan denied your request. The Plan says this provider is not a Medicare certified provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the nebulizer, with compressor (E0570) provided March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of neck (70491) and
CT scan of chest (71250).
You asked the Plan to pre-approve a CT scan of neck and CT scan of chest. You say that these imaging
services are medically necessary. The Plan denied your request. The Plan says follow up imaging is only
supported once per six months for the first year after treatment, then once a year after that.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a CT scan of neck and CT scan of
chest. Our reviewer says that the requested imaging services are not medically reasonable and necessary. Our
physician reviewer found that the CT of the neck and chest was completed on March 31, 2021, and findings
revealed post-surgical changes involving the left parathyroid gland, a small nodule of the right superior
mediastinum and no new suspicious pulmonary lesions were identified. Follow up imaging is only supported
once per six months for the first year after treatment, then once a year after that. The medical records do not
describe this imaging time frame. The review has determined that the requested CT scans are 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 a CT scan of neck and CT scan of chest have not been met. Therefore, we
decided that the Plan does not have to pre-approve a computed tomography (CT) scan of neck (70491) and CT
scan of chest (71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260).
You asked the Plan to pre-approve osseous surgery (D4260). You say that you have quickly advancing periodontal disease that can no longer be treated by a deep cleaning. You say that this is a necessary procedure, but you have minimal social security benefits and are unable to pay the fee out of pocket. The Plan denied your request. The Plan says the 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 osseous surgery (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), photochromatic tint (V2744), anti-reflective coating (V2750), progressive lenses (V2781) and polycarbonate lenses (V2784) provided on April 5, 2021.
You asked the Plan to pay for eyeglass frames and lenses. You say that your eyesight has been failing due to your macular degeneration and you required a pair of eyeglasses to achieve your activities of daily living. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you are limited to one pair of standard lenses and frames every two years. We looked at the file and the Plan's rules. The records show you exhausted your maximum allowed benefit on January 16, 2020. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), photochromatic tint (V2744), anti-reflective coating (V2750), progressive lenses (V2781) and polycarbonate lenses (V2784) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on December 29, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 had network providers available who could have provided the items/services at issue in this appeal. 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 an office visit (99213) provided on December 29, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on May 26, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was your annual eye exam so there should be no copayment. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that because the allowed amount for this service ($28.14) is less than your copayment obligation, you are responsible for the full allowed 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 $40 copayment for medical eye exams. You have been asked to pay a $40 copayment for the medical eye exam. The records show that this exam was not billed as a routine exam, but as a medical exam. Your doctor indicated that you were evaluated for both glaucoma and ocular hypertension, which are medical diagnoses. That is why the exam you had falls within the medical eye exams 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 medical eye exam you had on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the magnetic resonance imaging (MRI) of the pelvis and the MRI of the spine you had on April 15, 2021.
You asked the Plan to waive the copayments for the two MRIs. You say that you were told that getting two MRIs on one day would only result in one copayment. The Plan denied your request. The Plan says you were charged two separate copayments correctly.
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 $135 copayment for each MRI.
Records show that you had two MRIs. You have been asked to pay a $135 copayment for each of the two
MRIs. 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 magnetic resonance imaging (MRI) of the
pelvis and the MRI of the spine you had on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that this requested treatment is considered safe and effective. You say that the requested treatment is supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says the requested treatment is not medically necessary because there is 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 a Vertiflex Superion device. Our reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 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 Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212).
You asked the Plan to pre-approve a lower partial denture. You say that you lost your previous lower denture and need a new one so you can eat correctly again. The Plan denied your request. The Plan says you have exceeded frequency limits for this service and therefore it is 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. The Plan covers a lower partial denture once every five plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial denture was previously covered on September 13, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of a lower partial denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and psychotherapy provided from January 11, 2021, to February 8, 2021.
You asked the Plan to pay for the office visits (99213) and psychotherapy (90836). You say that you are being penalized by the Plan because your disorder is treated by doctors that opt out of Medicare. The Plan denied your request. The Plan says this provider chose not to receive Medicare funds so the charges cannot be paid.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visits and psychotherapy provided from January 11, 2021, to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture provided on February 3, 2021.
You asked the Plan to pay for the cone beam CT capture. You say that your teeth are brittle and continually
suffer cracks and breaks at the gum level. You say that you are under great financial burden and the services
should be covered. The Plan denied your request. The Plan says the 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 pay for the cone
beam CT capture provided on February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (75726, 75774) provided on December 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are bundled services. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 75726 and 75774 have a bundled relationship with code 37243 and cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (75726, 75774) provided on December 16, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says that rules for 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 SNF care. Our reviewer says that SNF care is medically necessary and reasonable. Our physician reviewer found you are a 73 year old male with a history of hypertension, pancreatic cancer, and small bowel obstruction. While you do not have documented skilled nursing needs, you do have documented skilled therapy needs. From the medical records provided, you are functioning below your baseline. There is no clear evidence provided that you have reached a plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Your care needs, as a practical matter, cannot 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted molecular pathology (CPT code 81479) provided to the enrollee on August 22, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered. 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 service have not been met. The ordering provider did not confirm the order for genetic testing. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology (CPT code 81479) provided to the enrollee on August 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 11, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the medical records support the medical necessity and the claim should be processed for payment. The Plan denied your request. The Plan says this code is not payable by Medicare.
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 pay for the self-administered drugs provided on March 11, 2021