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

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted his quality and functionality of life. The Plan denied your request. The Plan says there is a lack of evidence to support the device as 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 requested services. Our physician reviewer found that interspinous stabilization devices are experimental in spinal surgery. More research is needed to show safety and efficacy of the devices. Therefore, the requested services are not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Oxycontin 20 mg tablet.  You asked the Plan to pre-approve Oxycontin. You say that this medication is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin 20 mg tablet.   Benefits for Oxycontin 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sensors and receiver for a continuous glucose monitor (CGM).  You asked the Plan to pre-approve sensors and receiver. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of sensors and receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve sensors and receiver for a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services provided on April 5, 2021.  You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says separate payment cannot be made for these services.  The Plan must follow Medicare rules. Medicare rules say that ambulance transportation during an inpatient stay is included in Part A costs.   We looked at the file and Medicare rules. The records show that the enrollee was an inpatient when the ambulance services were provided. Payment for these services is included in the payment to the facility. Separate payment cannot be made for the ambulance services. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xgeva 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 is not being prescribed for a medically accepted indication.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Denosumab is not FDA approved for the treatment of hypercalcemia of unclear etiology. The enrollee's hypercalcemia appears to improve with the use of intravenous fluids. Use for this indication is not supported by major drug compendia or the medical literature. The note from the oncologist dated 11/22/21 states that the enrollee's case will be discussed with endocrinology and nephrology.          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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Botox injection you received on April 30, 2021.  You asked the Plan to waive the coinsurance for the Botox injection. You say that the doctor never mentioned that there would be coinsurance for the Botox injection.  You said that had the office told you about this coinsurance, you would not have had the service. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Botox injection. The Botox injection falls within the Medicare Part B drugs 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 and is clearly disclosed in your Evidence of Coverage. Therefore, we decided that the Plan does not have to waive the coinsurance for the Botox injection you received on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the second porcelain/ceramic retainer crown (D6740) provided as part of a dental bridge on May 26, 2021.  You asked the Plan to pay for the retainer crown. You say that this bridge was necessary and was partially denied due to a billing issue but should be covered in full. The Plan denied your request. The Plan says that only one crown per tooth may be covered every five years. The pontic (D6245) portion of this bridge was billed for the same tooth, and therefore this crown component is denied for payment.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, a complete dental claim form or any other evidence were not provided to substantiate that the D6740 crown is being billed for the same tooth that D6245 was billed. The only dental claim form in the file lists code D6245. Without evidence as to which tooth that code has been billed for, the Plan's denial is not substantiated. In addition, these services were received from a Plan-contracted provider and the Plan's contract states that one dental bridge may be covered every five years. Documentation indicates that the enrollee has not exceeded the frequency limitation for bridges at this time, as two of the three components for this single bridge were covered. Therefore, we decided that the Plan has to pay for the second porcelain/ceramic retainer crown (D6740) provided as part of a dental bridge on May 26, 2021.   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: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve palatopharyngoplasty for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show an apnea hypopnea index (AHI) or five or more.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the procedure. Our reviewer says that the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is troubled with loud snoring and daytime sleepiness. The most recent sleep study in 2013 showed mild obstructive sleep apnea with AHI of 8.4. There was no REM sleep, so this may be an underestimate of the severity of the apnea. The enrollee has tried continuous positive airway pressure in the past, and is intolerant.  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 procedure have been met. Therefore, we decided that the Plan has to pre-approve palatopharyngoplasty for the enrollee.   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 28 additional physical therapy visits.  You asked the Plan to pre-approve physical therapy. You say that the enrollee is unable to walk without assistance, therefore it is crucial that he continue with physical therapy. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy visits is correct, because the enrollee has not been progressing and a maintenance program can be performed with the demonstrated home exercise program.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not justify that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. It cannot be determined that the enrollee needs further therapy sessions and a skilled therapist's intervention.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 28 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an auricular stimulator.  You asked the Plan to pre-approve the requested services. You say that the goal is to help alleviate the enrollee's current pain. The Plan denied your request. The Plan says this is not a covered benefit for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need the SNF to regain your quality of life. The Plan denied your request. The Plan says that that the services you require can safely be received at a different setting.  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 SNF services are medically reasonable and necessary. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. The documentation does not show that you are at your prior level of function or that you have reached a new plateau in function. Daily skilled services are reasonably required to establish a maintenance program or to prevent deterioration of your condition. Our physician reviewer found that your condition meets 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 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) services.   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 waive the copayment for lab services you received on June 7, 2021.  You asked the Plan to waive the copayment for the lab services. You say that you had these labs in conjunction with an upcoming office visit. The Plan denied your request. The Plan says you were charged this copayment 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 $5 copayment for lab tests.   You have been asked to pay a $5 copayment for the lab services. 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 lab services you received on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the group two power wheelchair (K0821) and battery (E2365).  You asked the Plan to pre-approve the group two power wheelchair and battery. You say that the service is medically necessary. The Plan denied your request. The Plan says the physician office notes do not include a face-to-face encounter with information relative to the member's mobility limitation in the home and how it interferes with performance of activities of daily living or objective measurements of muscle strength, range of motion, gait, balance, and daily activity limitations.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 group two power wheelchair and battery. Our reviewer says that the service is not medically necessary. Our physician reviewer found the physician exam does not reveal a detailed upper extremity exam or gait evaluation supporting that the patient is unable to effectively ameliorate any mobility deficit with a   walker, cane, manual wheelchair or the inability to perform MRADLs in the home.  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 group two power wheelchair and battery have not been met. Therefore, we decided that the Plan does not have to pre-approve the group two power wheelchair (K0821) and battery (E2365).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).  You asked the Plan to pre-approve Superion interspinous spacer (Vertiflex device). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Superion interspinous spacer (Vertiflex device). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has longstanding low back pain. The vertilfex spacer 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 Superion interspinous spacer (Vertiflex device) have not been met. Therefore, we decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.  You asked the Plan to pre-approve SI RFA. You say that this procedure helps with your pain and mobility. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because sacroiliac (SI) joint radiofrequency ablation (RFA) 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 SI RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.  You asked the Plan to pre-approve compression stockings. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve arthroscopic rotator cuff repair for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is not reliably and sufficiently known to improve health outcomes in the documented clinical setting.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this overall clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right arthroscopic rotator cuff repair is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopic rotator cuff repair for the enrollee.