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

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.
You asked the Plan to pre-approve the dental service. You say that you have been examined by 2 different professionals. You say that they both agreed that you need a crown. You also say that you are experiencing a bad taste in your mouth because your tooth is not adequately protected. The Plan denied your request. The Plan says the x-ray provided does not show that there is a cavity below the crown.
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 covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided panoramic x-ray does not show any clear deficiencies of the margins. The reviewer also found that without further support of the need to replace the crown on #12 due to advancing caries, there is no medical necessity for a replacement crown. 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 the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electrical osteogensis stimlator (E0748).You asked the Plan to pre-approvean electrical osteogensis stimlator (E0748). You say that the requested electrical osteogenesis stimulator is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested osteogenesis stimulator.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 an electrical osteogensis stimlator (E0748). Our reviewer says that the enrollee does not meet Medicare criteria for the requested osteogenesis stimulator. Our physician reviewer found the enrollee is status post revision of lumbar laminectomy on 2/13/20. The enrollee's physician is requesting a bone growth stimulator due to fear that the bone won't fuse properly. In this case the enrollee recently underwent a single level fusion at L3-L4. The notes indicated two prior lumbar spine surgeries. The operative report indicates that the enrollee had previously undergone surgery at L4-L5. It should also be noted that the pre-operative MRI report noted surgical changes at L4-L5.In this setting it cannot be said that the enrollee would be considered to be "at high risk of pseudarthrosis due to previously failed spinal fusion at the same site "--as there was no indication in the notes that surgery had ever been performed at L3-L4. Nor did the enrollee undergo a multiple level fusion. For these reasons the requirements of the NCD have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrical osteogensis stimlator (E0748) have not been met.Therefore, we decided that the Plan does not have to pre-approvean electrical osteogensis stimlator (E0748).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Go Foot Drop System.
You asked the Plan to pre-approve the services. You say that you are not able to leave your house, because you
are afraid that you will fall. The Plan denied your request. The Plan says there is no indication of a spinal cord
injury, or muscular atrophy.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no note of a history of spinal cord injury. There is a history of lumbar spine surgery, but no
documentation of spinal cord injury. In as much it cannot be concluded based on the information provided that
this request meets criteria for coverage and thus the requested item would not be 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Go Foot Drop System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infliximab injection and chemotherapy administration provided on October 2, 2019.
You asked the Plan to waive the coinsurance for the infliximab injection and chemotherapy administration. You say that you thought your first payment covered both infusions. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance (including administration) for in-network Medicare Part B prescription drugs. You have been asked to pay a total of $412.43 for the infliximab injection and chemotherapy administration.
Service
Allowed Amount
Coinsurance
Member Liability
Infliximab Injection
$134.05
20%
$26.81
Chemotherapy Administration
$29.40
20%
$5.88
Chemotherapy Administration
$1,898.70
20%
$379.74
TOTAL:
$412.43
The infliximab injection and chemotherapy administration fall within the "Medicare Part B prescription drugs" 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 coinsurance for the infliximab injection and chemotherapy administration provided on October 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that your current orthotics no longer serve the purpose they were meant to serve.The Plan denied your request. The Plan says this item is nota 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-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be provided in the plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your
request. The Plan says this procedure is considered to experimental and investigational, due to a lack of
scientific evidence regarding the effectiveness of this procedure.
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 block. Our reviewer says that the
requested block is not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental and investigational procedure that is the subject of ongoing clinical trials.
Therefore, the procedure is considered not medically necessary or reasonable.
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 block have not been met. Therefore, we decided that the Plan does not have
to pre-approve bilateral genicular nerve block for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on October 17,
2019.
You asked the Plan to waive the copayment for physician services. You say that you are being billed but were
never seen on this date. 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 a $25
copayment per visit for Medicare-covered specialty care services.
You have been asked to pay a $25 copayment for physician services. Physician services fall within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The medical records confirm
that you received services on October 17, 2019. 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 physician
services provided on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia injections. You say that the enrollee has been taking bisphosphonates which have increased her bone density. However, she has recently gone off of them for a drug holiday and there is evidence in studies that resumption of bisphosphonates would not be as effective as beginning Prolia. The Plan denied your request. The Plan says the enrollee would be adequately treated with either oral or IV bisphosphonates.
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 the Prolia injections. Our reviewer says that the requested use of Prolia is not medically reasonable and necessary. Our physician reviewer found the enrollee had a DEXA scan noting T-score -1.7 in osteopenia range. Prolia is FDA supported for individuals with a diagnosis of osteoporosis or high risk fracture. Medical necessity is not supported. 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 Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on July 25, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the testing is
not being used to manage or treat a medical problem or diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We looked at the file and the rules. The records do not show that the tests were ordered by the physician who
furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the
management of the beneficiary's specific medical problem. There were insufficient records provided to show
the results of this testing would be used to determine a specific diagnosis or determine a specific treatment
strategy for disease or illness present in the enrollee at the time of service. Based on this information, we
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the genetic testing provided to the enrollee on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Bioness L300 Go System.You asked the Plan to pre-approvea functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system (E0770). You say that you need theBioness L300 Go System.The Plan denied your request. The Plan says the records show you do not meet the requirements.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 thePlan was correct in denying the request to pre-approve a functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system (E0770). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrolleehas been prescribed a functional electronic stimulation (FES) device for the management of foot drop related to their multiple sclerosis. In this case the enrolleedoes not have a history of a spinal cord injury (SCI). The enrolleeis noted to primarily be wheelchair bound and not otherwise ambulatory. The enrollee is also not shown to have undergone a "training program which consists of at least 32 physical therapy sessions with the device over a period of three months" as required for the NCD for coverage of the technology. In this setting it can be conclusively said that the requirements for coverage as defined by the NCD have not been met/satisfied. Therefore the requested item would not be eligible for coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a functional electrical stimulator, transcutaneous stimulationof nerve and/or muscle groups, any type, complete system (E0770) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Bioness L300 Go System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not shown this procedure to be helpful in people with similar pain problems.
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 RFA of the lateral sacral branches is considered experimental and investigational due to the very wide range of efficacy in the peer reviewed literature. Therefore, the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 21, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast ultrasound provided on October 7, 2019.
You asked the Plan to waive the coinsurance for the breast ultrasound. You say that you did not want to have this services done. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to 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 20% coinsurance up to $75 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $15.11 which is 20% of the allowed amount for the breast ultrasound. The allowed amount is $75.55. ($75.55 x 20% = $15.11). The breast ultrasound 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 coinsurance for the breast ultrasound provided October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on July 12, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on July 12, 2019.