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

We decided that the Plan does not have to pre-approvea consultation and 15 extractions to be provided by an oral surgeon.You asked the Plan to pre-approvethe consultation and extractions. You say that you are a cancer patient going through chemotherapy. You also say that if these teeth are removed you will not have any more problems, but cannot afford the cost of these services.The Plan denied your request. The Plan says your contract only covers dental services when they are performed by a participating general dentist.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 covered when they are received by an oral surgeon.Therefore, we decided that the Plan does not have to pre-approvea consultation and 15 extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ONIVYDE.
You asked the Plan to pre-approve ONIVYDE. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 ONIVYDE. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the ONIVYDE is medically reasonable and necessary for the enrollee. The documentation does not support that the ONIVYDE is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ONIVYDE have not been met. Therefore, we decided that the Plan does not have to pre-approve ONIVYDE.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 25, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you were transported by ambulance to the hospital where you remained for 6 days. You say that you are appealing the charge.The Plan denied your request. The Plan says the copayment 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 $200 per one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenitrous oxide (D9230) therapeutic parenteral drugs (D9612) other drugs or medicaments dispensed in the office or for home use (D9630) and oral hygiene instruction (D1330).You asked the Plan to pre-approvethe dental services. You say that you are requesting reconsideration of the denial because you do not have the funds to pay out of pocket so you need all of the servicesapproved.The Plan denied your request. The Plan says the requested services are not covered under the plan 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. Services not listed as a covered benefit is not covered by the plan.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-approvenitrous oxide (D9230) therapeutic parenteral drugs (D9612) other drugs or medicaments dispensed in the office or for home use (D9630) and oral hygiene instruction (D1330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that SCS implantation is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbosacral spondylolisthesis and back surgery in 1993. SCS is recommended only for selected patients that have failed less invasive procedures or are contraindicated. There is no documentation to support the specific need for SCS in this enrollee. The services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveComputed tomographic (CT) colonography (74263).You asked the Plan to pre-approvethe colonography. You say that the colonography should be covered because your reaction to sedation prevents you from having a traditional colonoscopy.The Plan denied your request. The Plan says CT colonography administered as a screening testis not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the colonography, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pre-approveComputed tomographic (CT) colonography (74263).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction provided on November 20, 2019.
You asked the Plan to pay for the eye refraction. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan does not cover eye refractions.
We looked at the file and the Plan's rules. Eye refractions are not a service that the plan covers. Based on this
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore,
we decided that the Plan does not have to pay for the eye refraction provided on November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Sol 30mg topical treatment.
You asked the Plan to pre-approve self-administered drugs. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-applied topical drugs are not covered under Medicare Par 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 Testosterone Sol 30mg topical treatment.
Benefits for self-administered drugs 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We lookedat 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 19, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy services for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be safely and effectively treated with IMRT.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is request for proton beam therapy to treat a 70-year-old woman with recurrent uterine leiomyosarcoma who has not had prior radiation therapy. The NCCN Guidelines Version 1.2020 Uterine Sarcoma, page UTSARC-5, recommends external beam radiation with or without brachytherapy and systemic therapy. The guidelines do not address or include the use of proton beam radiation. The documentation does not support that there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates. Therefore, the requested use of proton beam radiation is not 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens (V2500) purchased on April 12, 2019.You asked the Plan to pay for the contact lens. You say that the billing for $135 is incorrect. You were told as of May 30, 2018 that you had a balance of $100 for either glasses or contact lens. You had paid an additional $35 when you ordered your contacts.The Plan denied your request. The Plan says this request exceeds the eyewear benefit limit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when a $150 eyewear allowance once every 24 months. The records show that $140.56 was first applied on 6/19/17 and the $9.44 on 5/30/18 totaling $150. Therefore,the vision benefit is exhausted. We looked at the file and the Plan's rules. a $150 eyewear allowance once every 24months. Based on this information, we decided that the Plan's rules for coverage of the contact lens have not been met.Therefore, we decided that the Plan does not have to pay forcontact lens (V2500) purchased on April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to the plan to support that this drug is medically necessary. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotic lifts because you have one leg that is shorter than the other. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV insulin treatments for the enrollee.
You asked the Plan to pre-approve IV insulin treatments. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered experimental, investigational and/or unproven for all indications.
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 IV insulin treatments. Our reviewer says that IV insulin treatments are not medically reasonable and necessary for the enrollee. Intravenous insulin treatments are considered experimental, investigational and/or unproven for all indications. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of IV insulin treatments. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IV insulin treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve IV insulin treatments for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 21, 2019.You asked the Plan to pay forthe assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radio frequency ablation at lumbar 3, 4, and 5 levels.You asked the Plan to pre-approve bilateral radio frequency ablation. You say that this is medically necessary.The Plan denied your request. The Plan says the second MBB on the right side did not provide sufficient relief.The Plan follows Medicare rules. Medicare rules say that only when dual medial branch blocks (MBBs) provide at least 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with radiofrequency medial branch neurotomy be considered.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 bilateral radiofrequency ablation. Our reviewer says that Medicare coverage criteria have not been met. Our physician reviewer found the records do not show that the right side achieved adequate pain relief with previous injection therapy. Therefore, these services are not medicallyreasonable 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 bilateral radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral radiofrequency ablation at lumbar 3, 4, and 5 levels.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns-porcelain/ceramic substrate for teeth 2, 18 and 29 (D2740).
You asked the Plan to pre-approve the crowns. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the requested service is not listed as 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. Procedures not listed as a covered service is not covered by the plan. 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 crowns-porcelain/ceramic substrate for teeth 2, 18 and 29 (D2740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSelectMDx genetic testing.You asked the Plan to pre-approveSelectMDx genetic testing. You say that the treating physician wants the enrollee to have this test.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test 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 SelectMDxgenetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found guidelines state that given the lack of validation of the models/algorithms used in independent publications, the unclear behavior in other screened populations, and the lack of clarity regarding the incremental value and cost-effectiveness of this assay, this testing is not recommended at this time. This test is considered to be investigational at this time. There is no direct evidence that supports the clinical utility of the test, and the chain of evidence is incomplete due to the limitations in clinical validity and utility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SelectMDxgenetic testing have not been met.Therefore, we decided that the Plan does not have to pre-approveSelectMDx genetic testing.