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

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not an acceptable study. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, the enrollee is not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve minimally 
invasive lumbar decompression (0275T) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (66984) provided on June 21, 2021.

You asked the Plan to waive the copayment for surgical services. You say that the services should be covered as they were performed at an ambulatory surgical center. The Plan denied your request. The Plan says the cost sharing applied correctly based on the services rendered.

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 $225 copayment for Outpatient hospital services.

You have been asked to pay a $225 copayment for surgical services. The record shows that the services were provided at an outpatient facility that is run by the hospital. Surgical services fall within the Outpatient hospital services 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 surgical services (66984) provided on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pradaxa 150mg capsule.

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 a medical only policy with The Plan.

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 Pradaxa 150mg capsule.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network
(OON) vascular surgeon.

You asked the Plan to pre-approve the OON vascular surgery services. You say that the Doctor is an
experienced vascular surgeon whom you really like. You would like to use her for treatment of your varicose
veins and you know she does take your Plan. The Plan denied your request. The Plan says this provider is not in
your plan's network. There are other vascular surgeons who participate in your network and can provide the
care you require.

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 pre-approved care.

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
the medical services to be provided by out of network (OON) vascular surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances independently with no assistive device and is independent for transfers. Provided records 
do not document a significant decline in the enrollees functional status to necessitate daily inpatient skilled 
therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document that services in the home with home health care or in a long-term care 
facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour test strips for the enrollee.

You asked the Plan to pre-approve the Contour brand. You say that this is medically necessary. The Plan denied your request. The Plan says The Plan's preferred meters and test strips include: meters and test strips marketed by Roche (e.g. Accu-Chek Aviva Plus, Accu-Chek Guide, Accu-Chek Guide Me) or Trividia Health (e.g. TrueMetrix, TrueTrack).

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 Contour brand. Our reviewer says that the specific requested brand is not medically reasonable or necessary. Our physician reviewer found no medical records have been submitted for review. Therefore, there is no evidence to support that the requested brand of blood glucose test strips is medically necessary and reasonable. 

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 Contour brand have not been met. Therefore, we decided that the Plan does not have to pre-approve the Contour test strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2) ad bone 
replacement graft for ridge preservation (D7953 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you feel the services should be covered. 
The Plan denied your request. The Plan says the requested dental 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested guided tissue 
regeneration and bone replacement graft for ridge preservation are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2) ad 
bone replacement graft for ridge preservation (D7953 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on August 17, 2021. 
 
You asked the Plan to pay for the dental service. You say that the periodontal services were needed due to 
significant bone loss as well as potential loss of teeth. The Plan denied your request. The Plan says comprehensive periodontal 
evaluation 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 comprehensive periodontal 
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive periodontal evaluation (D0180) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; 
comprehensive, established patient (92014) provided December 29, 2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine exam 
and don't feel you should be charged a copayment. The Plan denied your request. The Plan says the copayment 
was applied 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 $10 
copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, 
including treatment for age-related macular degeneration.   
You have been asked to pay a $10 copayment for the medical eye exam. The medical eye exam falls within the 
Vision services 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 ophthalmological 
services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment 
program; comprehensive, established patient (92014) provided December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure 140mg/ml injection, for the enrollee.

You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed statin medications and had intolerance to all of them; this medication would be very beneficial in the treatment of the enrollee's cholesterol levels; chronic hyperlipidemia. The Plan denied your request. The Plan says Repatha Sure is on the self-administered drug list and is excluded from coverage under Part B. The Plan states the enrollee does not have pharmacy (drug) benefits administered by this Health Plan. The Plan states the enrollee does have a Plan which provides its own pharmacy benefits.

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 Repatha Sure 140mg/ml injection, for the enrollee.

Benefits for the medication 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid 75 mcg tablet for the enrollee.

You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the Plan.

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 Synthroid 75 mcg tablet for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of tooth #'s 1 and 14, alveoloplasty in conjunction with extractions on the upper right and upper left quadrants, and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue on tooth #'s 20 and 21 provided on July 3, 2019.

You asked the Plan to pay for the extractions, alveoloplasties, and localized deliveries of antimicrobial agents. You say that you did not receive radiation treatment. You also say that deep mouth cleaning and extractions were necessary given the severe pain and discomfort you experienced. The Plan denied your request. The Plan says alveoloplasty and localized delivery of antimicrobial agents are not covered services. The Plan also says that the extractions were processed according to The Plan Dental's negotiated rate.

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, alveoloplasty and localized delivery of antimicrobial agents are not among those covered under this benefit. The record also shows that this provider is non-participating with your plan. The record also shows that the Plan paid the in-network benefit rate (50% coinsurance) for each extraction and you are obligated to pay the remaining 50% coinsurance for each extraction. Therefore, we decided that the Plan does not have to pay for the extractions of tooth #'s 1 and 14, alveoloplasty in conjunction with extractions on the upper right and upper left quadrants, and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue on tooth #'s 20 and 21 provided on July 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 25mg/0.5ml syringe 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 the enrollee has a medical only policy with the Plan.

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 Enbrel 25mg/0.5ml syringe for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of the 
middle spine and MRI of the lower spine (72146 and 72158). 
 
You asked the Plan to pre-approve MRI scan services. You say that these imaging services are medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan services. Our reviewer says 
that the requested imaging services are not medically reasonable and necessary. Our physician reviewer found 
that Medicare states that imaging studies are covered when they are determined to be reasonable and necessary. 
In this case the member called her doctor's office reporting non-specific back pain. X-rays were done showing 
no findings of concern (in the thoracic and lumbar spine). 
 
There were otherwise no recent records provided for review with this request. There was no documentation of a 
recent physical exam or information on what (if any) interventions had recently been trialed for this complaint. There were no other findings that would permit a conclusion that the requested imaging studies are otherwise 
reasonable and necessary for the member at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the magnetic resonance imaging (MRI) scan of the middle spine and MRI of the lower 
spine (72146 and 72158).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay for tumor antigen, quantitative; CA 125 
(86304) provided on July 2, 2021. 
 
You asked the Plan to pay for the immunoassay for tumor antigen, quantitative; CA 125. You say that you 
would like reconsideration because your daughter has ovarian cancer and your doctor believes you are at risk. 
The Plan denied your request. The Plan says no symptoms nor personal history of cancer is documented. 
 
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 pay for the immunoassay for tumor antigen, 
quantitative; CA 125. Our reviewer says that the enrollee does not meet NCD criteria for coverage. Our 
physician reviewer found the enrollee does not have a covered indication per the NCD. 
 
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 immunoassay for tumor antigen, quantitative; CA 125 have not been met. 
Therefore, we decided that the Plan does not have to pay for the immunoassay for tumor antigen, quantitative; 
CA 125 (86304) provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 31, 2020, to 
September 1, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and appropriate. 
 The Plan denied your request. The Plan says that the criteria are not met for an inpatient stay, and the Plan will 
only pay for observation level care for these dates. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee required care in the inpatient setting due to her advanced age and presenting 
symptoms. She presented to emergency department (ED) on August 31, 2020, with complaints of dyspnea. She 
choked on dinner and was concerned for aspiration. Her medical history is significant for bronchitis, stroke, 
dementia, and hypertension. She was admitted for aspiration pneumonia. The enrollee had a directive of do not 
intubate, do not resuscitate, and comfort measures only. The enrollees power of attorney stated she did not 
want antibiotics and was interested in hospice care. The member was closely monitored overnight and on 
September 1, 2020, she was transferred to a hospice facility. The review has determined that the record showed 
that at the time of inpatient admission, the admitting physician reasonably expected that the enrollees 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 31, 2020, to September 1, 2020.  
 
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.