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

We decided that the Plan does not have to waive the copayment for the stress test rendered on December 18, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the denial. 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
Review of the file shows that you received a stress test on December 18, 2020. You have been asked to pay a $160 copayment for these services. These services fall within the Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility 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 stress test rendered on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for you, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. The services are experimental in nature and not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis provided on November 5, 2020.
You asked the Plan to pay for the orthosis. You say that the documentation indicates the services were medically necessary. The Plan denied your request. The Plan says the reasonableness of the equipment has not been established.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
The file shows that a lumbo-sacral orthosis was provided. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. In this case, the record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this orthosis. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the orthosis provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 dental crowns and 2 core buildup.
You asked the Plan to pre-approve 2 dental crowns (D2740) and 2 core buildup (D2950). You say that you need your front teeth repaired as it is affecting your health and wellbeing. The Plan denied your request. The Plan says you have exhausted your crown benefit and core buildup 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 2 dental crowns and 2 core buildup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation device and related accessories provided on September 7, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed supply code cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery from the billing provider for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulation device and related accessories provided on September 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the results from the prior test approved on 2/18/21 were not provided.
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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the enrollee had a case while hospitalized in May 2020 for vascular surgery that demonstrated ground glass infiltrates. There are insufficient medical records to evaluate the enrollee's current clinical status to determine whether the scan is medically reasonable and necessary as defined by Medicare rules. The case file also indicates that a CT scan was approved in February 2021 but has not been performed. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Opdivo (J9299).

You asked the Plan to pre-approve Opdivo. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested drug is not medically necessary because its use for the enrollee's condition is not medically supported.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the requested use of Opdivo is not FDA-approved for the enrollee's diagnosis. Neither is the use supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Opdivo (J9299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) and collection and application of autologous blood concentrate product (D7921) provided January 13, 2021.

You asked the Plan to pay for the bone replacement graft and collection and application of autologous blood concentrate product. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered under your dental benefits.

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 bone replacement graft for ridge preservation - per site (D7953) and collection and application of autologous blood concentrate product (D7921) provided January 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 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 daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 59-year-old female with paraplegia and foley catheter blockage and pyuria. In this case, there are no identifiable skilled nursing service needs. In addition, there are no identifiable skilled therapy service needs. Subsequently, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this request is medically necessary. The Plan denied your request. The Plan says the clinical information does not support that the criteria have been met for coverage.
The Plan follows Medicare rules. Medicare rules say that the radiofrequency ablation services are subject to the criteria listed 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 radiofrequency ablation services.
Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found This 85 year old woman has chronic low back pain. A recent magnetic resonance imaging scan shows a subacute L2 vertebral fracture, Severe formenal and central spinal stenosis. The patient has not had recent dual diagnostic MBBs. Because there are multiple other probable pain generators and the patient has not had recent duel diagnostic MBB, this request cannot be considered medically reasonable and 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 radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from September 23, 2020 to January 17, 2021.
You asked the Plan to pay for the home health care services. You say that you had a stroke, and you cannot move your left arm or leg. You say that your doctor said you needed home care. The Plan denied your request. The Plan says the services are custodial and not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care services. Our reviewer says that the home health care services are not medically necessary. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. It is unclear whether you meet the definition of home bound, as you appear to be able to attend in-office medical appointments. There is no evidence that you were receiving, or in need of, skilled nurse, skilled physical therapy (PT) or skilled occupational therapy (OT) services during the time period in question. As such, the home health services were not medically necessary or reasonable, and associated home health services were not coverable. 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 home health care services have not been met. Therefore, we decided that the Plan does not have to pay for home health care services provided from September 23, 2020 to
January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 17, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extraction (D7140), surgical removal (D7210), and alveoloplasty (D7310).
You asked the Plan to pre-approve dental services. You say that you have difficult eating and are in pain. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you were already approved for an extraction which exhausts this benefit and because alveoplasty is not covered by the Plan's dental benefits.
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 benefit for one extraction per calendar year has been exhausted and the requested alveoplasty is not covered by the Plan's dental benefits. Therefore, we decided that the Plan does not have to pre-approve tooth extraction (D7140), surgical removal (D7210), and alveoloplasty (D7310).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (81479) provided on November 29, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were not ordered by the treating physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services (81479) provided on November 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on February 9, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
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 problem focused limited oral evaluation provided on February 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and services of a home health/hospice aide (G0156).
You asked the Plan to pre-approve home health services. You say that you still need home health aide services. The Plan denied your request. The Plan says your needs can be met with a lower level of care.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the provided documentation does not indicate that you have documented skilled nursing needs. The reviewer found that you do not have documented skilled therapy needs. Therefore, the reviewer found that home health services are not
shown to be medically necessary and reasonable, and associated home health aide services are not coverable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and services of a home health/hospice aide (G0156).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says that a PET scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the requested PET scan is medically reasonable and necessary in this case. Our physician reviewer found that per FDA label, a PET CT scan with GA PSMA-11 is indicated for patients with rising prostate-specific antigen (PSA) after surgery. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization services provided on February 24, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim processed correctly.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules. The file shows that you received the Measles, Mumps, and Rubella (MMR) vaccine. The records do not show that you were injured or directly exposed to any illness related to the services provided. Therefore, we decided that the Plan does not have to pay for the immunization services provided on February 24, 2020.
Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.