Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 3, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this exam to be covered because you have 2 free exams under your plan. The Plan denied your request. The Plan says this service is not covered under your plan.

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. The only types of exams covered under your preventive dental services benefit are routine oral exams and comprehensive oral exams. Problem focused limited oral evaluation (D0140) does not fall under either of these types of exams. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397) provided on June 14, 2021.

You asked the Plan to pay for the knee brace and sleeve. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says this is not medically necessary per the records provided.

The Plan follows Medicare rules. Medicare rules say that knee braces may be considered medically reasonable and necessary when certain criteria (listed in the Medicare rules section) are met. 

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 the knee brace and sleeve. Our reviewer says that the criteria for the knee brace have not been met. Our physician reviewer found the right and left knee braces (L1851) and suspension sleeves (L2397) are not medically necessary. There is no evidence of a detailed properly performed neuromuscular examination or gait evaluation. There is no evidence of true instability of the knees on a physical exam. There is no pathological laxity on a knee exam with objective measurements of any laxity. There is no evidence of a recent surgery or injury to the knee. There is no evidence of a gait evaluation or indication the patient is current ambulatory and requires the requested knee braces and sleeves. 

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 knee brace and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397) provided on June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 290mcg Linzess capsules.

You asked the Plan to pre-approve the Linzess capsules. You say that you would like reconsideration because
the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is
not covered under 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 290mcg Linzess capsules.

Benefits for the Linzess capsules 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 pay for the drug testing provided on July 19, 2021 by an out-of-
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 referring provider 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 the drug testing provided on July 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgery consultation to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee needs to be seen for a follow up appointment. The Plan denied your request. The Plan says there are in-network providers available.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a surgery consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee's continued care could better provided in an outpatient, skilled nursing facility or long-term care facility setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular embolization (37243).

You asked the Plan to pre-approve the vascular embolization (37243). You say that he is not a good candidate for prostatic resection, and he was referred for artery embolization. You say that the embolization can be considered a treatment option in patients who are deemed to not be surgical candidates. The Plan denied your request. The Plan says this treatment is still considered experimental is not covered by Medicare.

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 vascular embolization (37243). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that prostatic arterial embolization is considered an experimental technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do not recommend this procedure outside of a clinical trial 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 the vascular embolization (37243) have not been met. Therefore, we decided that the Plan does not have to pre-approve the vascular embolization (37243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants.
You asked the Plan to pre-approve gingival irrigation. You say that gingival irrigation is required to complete
the deep cleaning of your teeth that has not been done for over 3 years. The Plan denied your request. The Plan
says gingival irrigation 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 gingival irrigation not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752).
You asked the Plan to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional methods. You say that this procedure is the most effective treatment at this time and should be authorized. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and effective.
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 surgery (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 that 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 surgery (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 surgery (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee
You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is experimental. More research is needed to show safety and efficacy of the 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot walk on your own and have even experienced falls this week in the hospital. You state that it is very unsafe for you to be home alone, you need care from trained professionals, and you also need physical therapy to regain your strength to be able to walk again. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and Coronavirus (COVID 19) pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213) and procedures (46600, 45330, 46221) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visits and procedures. You say that you have been seeing this provider for 20 years. The Plan denied your request. The Plan says there are in-network providers available for the requested services.

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 office visits (99213) and procedures (46600, 45330, 46221) 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 medical nutrition therapy.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of diabetes or kidney disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does
not have to pre-approve medical nutrition therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Yervoy.

You asked the Plan to pre-approve Opdivo and Yervoy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested drugs are not medically 
reasonable and 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 Opdivo and Yervoy. Our reviewer says 
that the combination of nivoumab (Opdivo) and ipilumumab (Yervoy) is FDA approved for first-line treatment 
of metastatic or recurrent non-small cell lung cancer (in combination with nivolumab and 2 cycles of platinum 
doublet chemotherapy) in adults with no EGFR or ALK genomic tumor aberrations. This patient had had 2 
prior lines of therapy, including with nivolumab, and has not had driver mutation testing. Our physician 
reviewer found the service is not reasonable or medically necessary or safe or effective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Yervoy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza caplet 24mcg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered medication does not fall under Part B coverage.

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 Amitiza caplet 24mcg for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve accu-chek smartview strips.

You asked the Plan to pre-approve accu-chek smartview strips. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided to the
enrollee by a preferred brand.

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 brand of diabetic supplies is not a preferred brand with the Plan. The Plan has preferred brands
available who can provide the items at issue in this appeal. Review of the file shows that the Plan's preferred
brands are Ascensia/Bayer products. There is no documentation to show that the enrollee has tried and failed
the preferred brand of diabetic testing supplies. We found no exception that would require the Plan to preapprove
these items/services. Therefore, we decided that the Plan does not have to pre-approve accu-chek
smartview strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 50mcg Synthroid tablets.
You asked the Plan to pre-approve the Synthroid tablets. You say that you would like reconsideration because
the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is
not covered under 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 50mcg Synthroid tablets.
Benefits for the Synthroid tablets 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health custodial care services.
You asked the Plan to pre-approve custodial care. You say that this is necessary for your condition. The Plan
denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the home
health custodial care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vitrectomy to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the service is available by a provider in the enrollee'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. 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 preapprove
these items/services. Therefore, we decided that the Plan does not have to pre-approve the vitrectomy
to be provided by an out-of-network provider