Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary, as it would be
successful to treat your condition. The Plan denied your request. The Plan says the requested services do not
meet the accepted standards of care.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat
symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety
and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial
setting. As such, PAE in this case 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve prostate artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hyperbaric oxygen therapy (99183) acupuncture (97813) and infrared therapy (97026) provided on April 9, 2019 to April 26, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that you believe that since these services were deemed necessary to help treat the enrollee's condition, they should be covered. The Plan denied your request. The Plan says the enrollee was asymptomatic with no chronic pain or wounds noted at the time of service so the criteria has not been met for acupuncture and HBP therapy. Infrared therapy is not a covered service.

The plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. 

The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/services at issue. Page 28 of the Plan's Schedule of Cost Sharing says that for physician services prior authorization rules may apply for network services and prior authorization is recommended when provided by an out of network provider.

The Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that acupuncture is covered for the relief of chronic pain or in place of anesthesia for a surgical or dental procedure covered under the Plan. The person providing the acupuncture must be a physician licensed to perform the services. The enrollee was asymptomatic with no chronic pain or wounds noted at the dates of service. Infrared therapy is not a covered service.

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 the hyperbaric oxygen therapy (99183) acupuncture (97813) and infrared therapy (97026) provided on April 9, 2019 to April 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80074, 82306, 82607, and 82746) provided to the enrollee on January 26, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says these lab services were ordered as a screening and are not covered by Medicare.

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 was 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 pay for lab services (80074, 82306, 82607, and 82746) provided to the enrollee on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found Keytruda and Lenvatinib is denied as
they are only approvable in MSS (microsatellite stable) uterine cancer, they are not approvable in ovary cancer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87799, 87798, 87482) provided February 19,
2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says PCR urine testing is considered investigational and is not covered.
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 pay for the lab services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and
sensitivity. The PCR testing is considered unproven and not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services (87799, 87798, 87482) provided February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on December 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit has been reached.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $10 copayment for up to 30 visits each calendar year for routine chiropractic services. Review of the file shows that the enrollee was provided routine chiropractic services on December 23, 2020. The records show that the Plan had paid for 30 routine visits prior to the visit in question. This means that the visit in question exceeds the benefit limit and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foam dressing.

You asked the Plan to pre-approve the dressing. You say that this is medically necessary. The Plan denied your request. The Plan says the wound does not meet the criteria.

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 dressing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a recent note stated that the wound was 2x1x0.1cm with small serosanguinous drainage and 100% granulation. A request for foam dressing was made, but not sufficiently supported. There was no recent surgery or debridement of the wound and it did not have significant amounts of draining. Therefore, this request for foam dressing will be considered not medically necessary based on the provided documentation. 

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 dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve a foam dressing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided November 1, 2019.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says this claim has denied as it is untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the subsequent nursing facility care was not filed until February 3, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 low air loss mattress.

You asked the Plan to pre-approve low air loss mattress. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for this mattress.

The Plan follows Medicare rules. Medicare rules state that a group 2 low air loss mattress is only covered under certain clinical criteria. 

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 low air loss mattress. Our reviewer says that the enrollee does not meet the Medicare criteria for this mattress. Our physician reviewer found the enrollee has one ulcer which appears to be successfully healing with current treatment. He does not have multiple ulcers which are required to meet criteria for this mattress. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of low air loss mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 low air loss mattress.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate as a bone graft substitute. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. 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.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Gelsyn-3. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered from March 12, 2021 to March 19, 2021.
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 the claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid primary diagnosis code. 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 occupational therapy services rendered from March 12, 2021 to March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain crown (D2740) provided on
December 16, 2020.
You asked the Plan to reimburse you for the dental service. You say that you thought that even out of network,
this would be covered. The Plan denied your request. The Plan says porcelain crown is not listed as 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.
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 reimburse you for
the porcelain crown (D2740) provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and contact lens fitting received on January 11, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary to get assistance inserting contact lenses into the eye. The Plan denied your request. The Plan says this was billed incorrectly.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for an eye exam and contact lens fitting received on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 2020.
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 the services are not covered.
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, a cardiovascular risk assessment panel, was 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 pay for the laboratory services rendered on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings (A6531).
You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 stockings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria is not met as there is no evidence of a wound for which to treat with the compression stockings as required. Therefore, this request for compression stockings will be considered not 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 the stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve compression stockings (A6531).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain management injection (CPT 64633) for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the criteria has been met.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there has not been a second confirmatory set of diagnostic medical branch blocks. A prior radiofrequency procedure has not been done at the same level. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a pain management injection (CPT 64633) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided on October 9, 2020.
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance transport provided on October 9, 2020.