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

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. 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.
The documentation shows that the plan uses Local Coverage Determination, (LCD) L33270 to support their denial. However, LCD L33270 is not valid for the enrollee's home state of North Carolina. Therefore, LCD L33270 does not have jurisdiction and we cannot use it to substantiate our decision. 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 Prolia. Our reviewer says that the documentation does not support that the requested Prolia is medically reasonable or necessary. Our physician reviewer found the documentation does not support that indications for Prolia have been met. The enrollee must try and fail first line bisphosphonate therapy. There is no documented contraindication in the records. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the brain (70551) provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the MRI of the brain. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 a magnetic resonance imaging (MRI) of the brain (70551) provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided in an outpatient hospital facility on April 8, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because this was a pre-operative visit. 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 $50 copayment for X-rays provided in an outpatient hospital facility. You received an X-ray at an outpatient hospital facility on April 8, 2019. An X-ray is not included in a pre-operative visit. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an X-ray provided in an outpatient hospital facility on April 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts.
You asked the Plan to pre-approve diabetic shoes and inserts. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary and you do not meet criteria for coverage of these items.
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 diabetic shoes and inserts. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. You have a history of diabetes and cardiac problems. You have pes planovalgus and a history of gastrocnemius lengthening procedures. On exam, you have no records of significant calf pain to squeeze and you have no calf swelling. When the provider palpates your calf, there are no distinct masses. Pain seems to be located within the muscle mass itself. Your feet do not demonstrate any ulcerations or impending ulcerations at this time. There is no documentation of diabetic ulcerations or other indications for this service. This is a convenience item and is therefore not medically necessary. Our physician reviewer found that your condition does not meet Medicare criteria for diabetic shoes and inserts.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic shoes and inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on September 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon services are not payable for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 26615. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided at an outpatient hospital facility on October 17, 2019.
You asked the Plan to waive the copayment for a duplex scan. You say that you disagree with the charges because the hospital is the only place you can receive services on your island. 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 $170 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. You have been asked to pay the allowed amount of $146.22, which is less than the $170 copayment for a duplex scan. A duplex scan falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a duplex scan provided at an outpatient hospital facility on October 17, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Euflexxa for the enrollee.You asked the Plan to pre-approve Euflexxa. You say that the enrollee cannot walk and has total pain in both knees.The Plan denied your request. The Plan says that that there was no documentation showing the enrollee tried and failed physical therapy or modification activities.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 Euflexxa. Our reviewer says that Euflexxa is medically reasonable and necessary for the enrollee in this case. This enrollee presents with persistent bilateral knee pain. Functional limitations are reported in weight bearing activities. Clinical exam findings are consistent with imaging evidence of advanced osteoarthritis. She has failed to adequately improve with prior cortisone injections to the knees, and conservative treatment including medications, ambulatory assistive device and activity modification. Under consideration is a request for Euflexxa injections of both knees. Evidence based medical peer-reviewed literature supports the use of visco supplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current evidence based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. A trial of Euflexxa injections is reasonably indicated for treatment of this enrollee's knee pain given the failure of reasonable and/or comprehensive conservative treatment, worsening pain and functional limitations, and to potentially delay surgical treatment. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Euflexxa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have been met.Therefore, we decided that the Plan has to pre-approve Euflexxa for the enrollee.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on December 9, 2019.
You asked the Plan to pay for the dental services. You say that the provider informed you the services were covered. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The Plan states they contacted the provider to confirm the benefits you were quoted. The Plan states the provider advised that your Medicaid was billed and the remaining balance was adjusted off your account and you do not owe any amount to the provider. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on December 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the thorax (71260), CT scan of the abdomen and pelvis (74177), and low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (Q9966) provided on July 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the CT scan of the thorax, CT scan of the abdomen and pelvis, and low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 a computed tomography (CT) scan of the thorax (71260), CT scan of the abdomen and pelvis (74177), and low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (Q9966) provided on July 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on September 30, 2019.
You asked the Plan to pay for the advance care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate; therefore, the billed service cannot be verified. The submitted medical records do not include the documentation of a discussion between the provider and the patient, along with family member(s), or surrogate(s), regarding eventual end-of-life decisions and preferences; therefore, the advance care planning service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a urinalysis procedure provided on November 26, 2019.
You asked the Plan to pay for the urinalysis procedure. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for a urinalysis procedure provided on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested procedures are not considered medically reasonable and necessary in this case. Our physician reviewer found the device in question is experimental. More research is needed to justify its use. 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 insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility services provided from August 18, 2019 to August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that these 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 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 forthe skilled nursing facility services provided from August 18, 2019 to August 26, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee from April 29, 2019 to May 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 20610, 27486, and 11044 are not supported.
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 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. The definition of code 27486 is revision of total knee arthroplasty, with or without allograft; 1 component. The definition of code 11044 is debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. We find that CPT codes 20610, 27486 and 11044 are not supported in the medical record. Specifically, the operative report does not include documentation of an arthrocentesis for a major joint or bursa was performed to support code 20610. The operative report does not include documentation of revision of a total knee arthroplasty to support code 27486. The operative report does not include documentation of debridement into the bone for the first 20 sq cm or less to support code 11044. 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 pay for the services rendered to the enrollee from April 29, 2019 to May 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing provided on November 25, 2019.
You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation indicates that train of four testing was performed. It is inappropriate to bill this code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the frenulectomy, the alveoplasty, or the removal of bone growths.You asked the Plan to pre-approve the frenulectomy, the alveoplasty, and the removal of bone growths. You say that you are unable to eat and you have been forced to swallow your food whole. The Plan denied your request. The Plan says the services are not covered 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 frenulectomy, the alveoplasty, and the removal of bone growths are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approvethe frenulectomy, the alveoplasty, or the removal of bone growths.