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

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRIs) of the spine.You asked the Plan to pre-approve MRIs. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the records do not show a 6-week trial of conservative management.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 MRIs. Our reviewer says that the enrollee meets the Medicare criteria for the requested MRIs. Our physician reviewer found the enrollee's pain has been present chronically and had radicular nature,therefore the requested MRI studies are indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRIs have been met.Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRIs) of the spine.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve provided on June 28, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthoses were
not 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 orthosis (L1851) and suspension
sleeve (L2397). Our physician reviewer found the enrollee's chief complaint was knee pain. The documentation
in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and
necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no
documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is
insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately
payable when the base item is not covered.
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 orthosis (L1851) and suspension sleeve (L2397) have not been met.
Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve
provided on June 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the maxillary partial denture (D5213) provided on
July 21, 2019.
You asked the Plan to reimburse you for the dental service. You say that this situation was out of your control.
You say that the treatment was an emergency dental treatment due to a dislodged bridge from your tooth. The
Plan denied your request. The Plan says only emergency conditions are covered when you are out of area, not
urgent. The Plan says the services you received do not meet the definition of emergent. The Plan says that you
could have returned home for the bridge without risking your health.
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 partial denture does not meet the
definition of an emergent dental service. The record shows that you initially saw the dentist on July 13, 2019
for this issue and then returned on July 21, 2019 to receive the bridge. Although the services may have been
urgent, they were not emergent. Therefore, we decided that the Plan does not have to reimburse you for the
maxillary partial denture (D5213) provided on July 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve XIIDRA 5% Eye drops for the enrollee.
You asked the Plan to pre-approve XIIDRA 5% Eye drops under Medicare Part B. You say that these eye drops are medically necessary. The Plan denied your request. The Plan says the eye drops requested are 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 XIIDRA 5% Eye drops for the enrollee.
Benefits for XIIDRA 5% Eye drops 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 4, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you would like this claim paid.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for an office visit provided on March 4, 2019 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on June 18, 2019
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on June 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342).
You asked the Plan to pre-approve the dental service. You say that this service is mandatory for your overall health. You say that you need this service because your last dental visit resulted in an extremely poorly executed cleaning and a chipped tooth. You also say that your general health is being directly affected. The Plan denied your request. The Plan says the requested dental service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for low osmolar contrast material (Q9967) provided on September 12, 2019.
You asked the Plan to pay for the low osmolar contrast material. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support that low osmolar contrast material, 300-399 mg/ml iodine concentration was administered on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml . We asked our coder 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 low osmolar contrast material. Our reviewer says that CPT code Q9967 does not meet criteria for billing or reimbursement criteria. Our reviewer found the medical
records provided do not include documentation of low osmolar contrast material, 300 - 399 mg/ml iodine concentration per ml. Therefore, the service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for low osmolar contrast material (Q9967) provided on September 12, 2019.
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 the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no skilled care needed.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 the admission 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for renal laboratory testing provided on August 22, 2019 to September 10, 2019 by out of network provider
You asked the Plan to pay for renal laboratory testing. You say that specialized renal laboratory testing was provided. You say that this service may not be available from laboratories that are in-network. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider, is also out-of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 renal laboratory testing provided on August 22, 2019 to September 10, 2019 by out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 25, 2018.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 25, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional LogistiCare mileage.You asked the Plan to pre-approveadditional LogistiCare mileage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you are asking for a total of 61 miles per one-way trip to your destination. The Plan says that your contract clearly states you are only covered for up to 50 miles per one-way trip.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are asking for a total of 61 miles per one-way trip to your destination. Your contract clearly states you are only covered for up to 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approveadditional LogistiCare mileage
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee is not able to walk on his own and has not mastered the wheelchair yet.The Plan denied your request. The Plan says that the enrollee no longer requires skilled services and the continuation of SNF is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued 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 not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor for the enrollee.
You asked the Plan to pre-approve Crestor. The Plan denied your request. The Plan says the enrollee's medical
plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Crestor for the enrollee.
Benefits for Crestor 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 Hyzaar tablets for the enrollee.
You asked the Plan to pre-approve Hyzaar tablets. You say that Hyzaar tablets are medically necessary. The
Plan denied your request. The Plan says Hyzaar tablets are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Hyzaar tablets for the
enrollee.
Benefits for Hyzaar 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 28, 2019 by an out of network provider. You asked the Plan to pay for outpatient lab work. You say that you performed all tests that were ordered by the referring physician. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the ordering provider is also an out-of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 outpatient lab work provided on September 28, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 16, 2017.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the servicesat issue in this appeal. The Plan did not pre-approve the services 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 forthe medical services provided to the enrollee by an out-of-network provider on November 16, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator and humidifier (E0466 and E0550).
You asked the Plan to pre-approve a home ventilator and humidifier (E0466 and E0550). You say that the requested home ventilator and humidifier are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator and humidifier.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator and humidifier (E0466 and E0550). Our reviewer says that the enrollee does not meet criteria for the requested home ventilator and humidifier. Our physician reviewer found the enrollee was admitted recently with dyspnea, fever, in afib with rapid ventricular rate, pneumonia, and positive for strep pneumonia. The enrollee was treated with BiPAP, initially some difficulty tolerating, but used it overnight and improved. Coverage criteria for a home ventilator are not met. The enrollee has chronic obstructive pulmonary disease (COPD), with chronic hypercapnic and hypoxic respiratory failure. The enrollee appears to qualify for BiPAP support at night. However, Medicare does not cover a home ventilator when used as a BiPAP device. Certain BiPAP devices are capable of providing the AVAPS-AE mode, if that is considered necessary. There is no evidence of failure of BiPAP. A home ventilator is considered not medically necessary 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 a home ventilator and humidifier (E0466 and E0550) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator and humidifier (E0466 and E0550).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee.
You asked the Plan to pre-approve the sensor and transmitter. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that these items are not classified as durable medical equipment.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee.