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

We decided that the Plan does not have to pre-approve MRI of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because you have been waiting for this study for months and are suffering from pain. The Plan denied your request. The Plan says the documentation does not show that you have tried and failed conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Specifically, the record does not include any clinical information to determine if Medicare coverage criteria have been met. Of note, the Plan has provided evidence of attempts to retrieve medical records without response. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET of the whole body (78816).
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because this service is essential and treatment may be necessary. The Plan denied your request. The Plan says this service is not medically necessary or the standard of care.
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 the PET. Our reviewer says that the ordering physician has a minute concern about a malignancy because of the presence of two abnormal protein spikes and thrombocytosis. There are other tests being performed, including a bone marrow biopsy. Our physician reviewer found this service 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 PET have not been met. Therefore, we decided that the Plan does not have to pre-approve PET of the whole body (78816).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L1833, L2397) provided on August 21, 2020.
You asked the Plan to pay for knee braces. You say that this was medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 for the supplies provided in this case. While the submitted documentation includes a delivery ticket, there is no documentation from the delivery service showing evidence of delivery. 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 knee braces (L1833, L2397) provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and intraoral periapical radiographic images (D0220, D0230 x3) provided on December 8, 2020.
You asked the Plan to pay for a panoramic radiographic image and intraoral periapical radiographic images. You say that you were not informed that these services would not be covered. The Plan denied your request. The Plan says panoramic radiographic images are a covered benefit, but you have exceeded the frequency limit of one every 3 years. Periapical radiographic images are not 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a panoramic radiographic image and intraoral periapical radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for full mouth or panoramic radiographic images prior to this service on February 24, 2020. Additionally, periapical radiographic images are not a covered service. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and intraoral periapical radiographic images (D0220, D0230 x3) provided on December 8, 2020.
Your complaint about the provider potentially not informing you of the services not being covered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvethe CardioMEMS device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms (currently ClassIII) and has resulted in a recent acute hospitalization. This is especially difficult in this enrollee, given the severe obesity and other pulmonary disease, making evaluation of fluid status, symptoms and signs of CHF by physical exam even more challenging. The CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Given the severe symptoms of persistent CHF which appears very sensitive to volume loading conditions (recent LVEDP was 36 mmHg on cath), complexity of his medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMS device is not investigational, is reasonable and necessary and has both clinical data and expert opinion to support its use in this  clinical situation.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 device have been met.Therefore, we decided that the Planhas to pre-approvethe CardioMEMS device for the enrollee.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided .You asked the Plan to waive the copayment foremergency care. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $65 copayment for emergency care. The medical records show that you received emergency care. Therefore, you are responsible to pay the $65 copayment. You have been asked to pay a $65 copayment for emergency care. Emergency care falls within the emergency care 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 foremergency care provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDupixent for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered under 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-approveDupixent for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional sessions of transcranial magnetic stimulation (TMS) treatment for the enrollee.You asked the Planto pre-approvethe additional sessions. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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 the additional sessions. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not believed that the enrollee will improve with the fifteen sessions that have already been authorized. The enrollee has not shown a 50% improvement based on the standard rating scales including the PHQ9 and MADRS.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 additional sessions have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional sessions of transcranial magnetic stimulation (TMS) treatment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided thatthe Plan does not have to pay forthe removal of impacted tooth, bone replacement graft for ridge preservation, and first 15 minutes of deep sedation/general anesthesia provided .You asked the Plan to pay forthe removal of impacted tooth, bone replacement graft, and deep sedation/general anesthesia. You say that this claim should be handled as a jaw surgery operation, not as dental work, and should be covered.The Plan denied your request. The Plan says these 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 Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess ofMedicare 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 forthe removal of impacted tooth, bone replacement graft for ridge preservation, and first 15 minutes of deep sedation/general anesthesia provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's needs are primarily custodial.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 denyingthe request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to the current acute care hospital with fatigue, COVID-19 pneumonia, acute respiratory failure, and recently treated deep vein thrombosis (DVT)/pulmonary embolism. Recent notes suggest increasing oxygen requirements. The enrollee appears to be more unstable, requiring more oxygen. She needs additional short-term acute care services to be stabilized, which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Consideration for transfer may be made soon when treatment has completed and the enrollee is more stable.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTumor Treatment Field Therapy.You asked the Plan to pre-approveTumor Treatment Field Therapy. You say that you would like reconsideration because this is the most appropriate option for the member at this time.The Plan denied yourrequest. The Plan says the member does not have a diagnosis of glioblastoma.The Plan follows Medicare rules. Medicare rules say that Tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed Glioblastoma Multiforme.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 Tumor Treatment Field Therapy. Our reviewer says that the LCD isspecific in requiring pathologic diagnosis of supratentorial glioblastoma, reflecting the standard of care use for this device. Our physician reviewer found this member does not carry a diagnosis of glioblastoma.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tumor Treatment Field Therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveTumor Treatment Field Therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of retrolisthesis and anterolisthesis with no discussion of spinal instability on flexion/extension films. There is imaging evidence of levoscoliosis and dextroscoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack ofsignificant osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Device atL3-4, L4-5 is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedry pressure mattress (CPT code E0184) and total electric hospital bed (E0296).You asked the Plan to pre-approvethe DME. You say that you are unable to get out of your bed and your wife is unable to assist you.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the file show that you a total electric hospital bed is not covered by Medicare. Furthermore, the records show that you do not meetthe criteria for a dry pressure mattress because you are able to get around with a cane, do not show poor nutrition, and the records do not show that you are unable to control your bowels or urine.Therefore, we decided that the Plan does not have to pre-approvedry pressure mattress (CPT code E0184) and total electric hospital bed (E0296).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional physical therapy (PT) visits.You asked the Plan to pre-approvethe PT visits. You say that the enrollee is progressing well, but still lacking proper knee stability during balance exercises. The enrollee will benefit from skilled PT intervention.The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for continuation of outpatient physical therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be able to transition to an independent home exercise program with the authorized therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
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 PT visits have not been met.Therefore, wedecided that the Plan does not have to pre-approve4 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided .You asked the Plan to pay forthese items. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the claim is not payable as it appears that the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered if the beneficiary has had recent injury to or a surgical procedure on the knee. A knee orthosis also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the LCD-related Policy Article. Knee instability must be documented by examination of the beneficiary and objective description of joint laxity.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 these items. Our reviewer says that the knee orthosis and thesuspension sleeve provided were not medically necessary. Our physician reviewer found that the documentation in the case file does not support that the knee orthosis and suspension sleeve provided 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 a recent surgical procedure on the enrollee's knee. There is insufficient documentation of an appropriate evaluation of the enrollee, as well as insufficient credible objective documentation of joint laxity. Additionally, the suspension 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 these items have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided .