Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram.You asked the Plan to pre-approve the services. You say that you were hospitalized last year for heart failure for 10 or 11 days.The Plan denied your request. The Plan says that there is no recent change in cardiac status.The Plan must follow Medicare rules. Medicare rules say that echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function.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 considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, you have a cardiomyopathy associated with congestive heart failure requiring hospitalization that partially improved with medication based on an echocardiogram almost 2 years ago. In this circumstance afollow up echocardiogram almost 2 years from the prior exam to reassess left ventricular size and ejection fraction is reasonable and appropriate according to current guidelines. Coverage criteria are met since one covered indication includes cardiomyopathy and "it is not generally medically necessary to augment clinical assessments with TTE measurements at more frequent than annual examinations."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 been met.Therefore, we decided that the Plan has to pre-approve a transthoracic echocardiogram.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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce thecopayment forradiation treatment management from $175 to $55. We decided that the Plan does not have to waive the copaymententirely to a $0 copayment. You asked the Plan to waive the copayment forradiation treatment management. You say that youdo not understand why you have to pay $175 and the Plan only paid $23.33.The Plan says that a daily specialist copay will also apply for radiation therapy management. Code 77427 is a weekly unit of treatment management which is equal to five fractions or treatment sessions.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 $20 copaymentplus a daily specialist copayment of $35 per provider, per day for Radiation Therapy services.The Plan states that you must pay a $35 specialist copayment per fraction. However, the EOC does not make it clear that you must pay a specialist copayment per fraction, as processed by the Plan. The Plan did not follow Medicare rules for disclosure of cost-sharing information in clear and accurate terms. Therefore, we decided that the Plan has to reduce the copayment from $175 to $55 for each copayment at issue.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe high risk HPV testing provided on July 18, 2019.You asked the Planto pay forthe lab testing. You say that this was a medically necessary test that should be paid.The Plandenied your request. The Plansaysthatthis code is statutorily excluded from payment on the Physician Fee Schedule so this means that it is not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan's denial is based on the fact that the code 87624 has a status indicator of "X" on the Physician Fee Schedule. While this is correct, this only means that it is not payable on the Physician Fee Schedule, not that it is not covered. As a lab test, this is payable on the Clinical Laboratory Fee Schedule. There is no apparent reason that this testing would be noncovered and no alternaterationale has been offered by the Plan. As such, we find that this denial of payment is not supported.Therefore, we decided that the Planhas to pay forthe high risk HPV testing provided on July 18, 2019.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 to review. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve flex-walk system lower extremity prosthesis (L5981) and multi-axial rotation unit (L5986) to be provided.
You asked the Plan to pre-approve the prosthesis with advanced foot and ankle feature. You say that there is no evidence that the enrollee will not be able to function at a K3 level with the appropriate prosthesis. The Plan denied your request. The Plan says that the requested K3 foot exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and necessary.
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 prosthesis with advanced foot and ankle feature. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Medicare criteria have been met for the requested L5981 and L5986 codes based on his anticipated K3 functional level. Therefore, this request for an advanced foot and ankle is 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 prosthesis with advanced foot and ankle feature have been met. Therefore, we decided that the Plan has to pre-approve flex-walk system lower extremity prosthesis (L5981) and multi-axial rotation unit (L5986) to be provided.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the urgent care visit provided on September 1, 2019.You asked the Plan to pay for the urgent care visit. You say that you feel that this should be covered because you had swelling and an infection which required antibiotics.The Plan denied your request. The Plan says that this visit was due to tooth pain and no coverage is available for any condition involving the teeth.The Plan must follow Medicare rules. Medicare rules say that dental care is not covered.In this case, the visit to the urgent care center is not considered dental care. No care or treatment of the teeth was provided on this visit. The enrollee had pain, swelling, and evidence of facial cellulitis, all of which are medical conditions, not dental conditions. As such, we find that this visit is covered by Medicare.Therefore, we decided that the Plan has to pay for the urgent care visit provided on September 1, 2019.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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for(CPT Code A5500) and (CPT Code A5513) provided to the enrollee on July 23, 2019.You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says that the service HCPCS codes A5500 and A5513 are not authorized because the provider billed for services and there is no record of proof of delivery for this service. The Plan states that the provider is listed on the claims as the referring physician; however, the medical records submitted by providers do not contain the above-listed information. The Plan states after at least three requests for this information to the DME provider and the physician listed on the claim, none was received.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 been met. The Proof of Delivery was sent.Therefore, we decided that the Plan has to pay for(CPT Code A5500) and (CPT Code A5513) provided to the enrollee on July 23, 2019.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: Favorable

We decided that the Plan has to pre-approve a complete mandibular denture to be provided.You asked the Plan to pre-approve the complete mandibular denture. You say that you need a new denture because you recently fell and broke some of your remaining teeth.The Plan denied your request. The Plan says that this service is allowed one time in 5 years. The Plan also says the record shows that you have already received this service within the past 5 years and reached the limit for this service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable 2019 Evidence of Coverage for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pre-approve a complete mandibular denture to be provided. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve home health skilled nursing visits. You asked the Plan to pre-approve home health care. You say that you have an issue with your leg and have had 3 knee surgeries.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because your needs can be met by a custodial level of support and skilled home health care is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted any medical records, nor has the plan submitted any documented attempts to obtain medical records. You say that these services are necessary for you based on your conditions. The Plan says that skilled care is not necessary and your needs can be met at a custodial level of care. Without medical records, the Plan has not shown that their denial on this basis is medically justified or correct according to Medicare rules.Therefore, we decided that the Plan has to pre-approve home health skilled nursing visits.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve image-guided radiation therapy. 
 
You asked the Plan to pre-approve image-guided radiation therapy. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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 image-guided radiation therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that image-guided radiation therapy is a type of external beam radiation therapy, and more specifically a conformal radiation therapy. It allows 3-dimensional treatment of an area while minimizing toxicity to surrounding areas. It is a standard of care. The enrollee has a squamous cell cancer of unknown primary with resection of a mass from the right inguinal area. Radiation is standard to decrease risk of recurrence including use of image-guided radiation therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of image-guided radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve image-guided radiation therapy.  
 
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea pneumatic compression device (PCD) identified with code E0652.You asked the Plan topre-approvea PCD identified with code E0652. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested item is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PCD identified with code E06052 is covered for certain indications.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 a PCD identified with code E0652. Our reviewer says that the documentation supports that the requested PCD is medically reasonable and necessary. Our physician reviewer found you have intractable lymphedema of the lower extremities bilaterally due to iliocaval obstruction for which efforts at recanalization have not been successful. There is medical record documentation of severe pain and requirement for narcotic pain medication and failure at efforts of conservative therapy including theuse of a more basic pump. Iliocaval obstruction and severe pain and intolerance to standard compression are satisfactory unique characteristics of your condition that would warrant the higher-level pump coded as E0652. Therefore, you meet criteria for the requested device.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 PCD identified with code E0652 have been met. Therefore, we decided that the Plan has to pre-approvea pneumatic compression device (PCD) identified with code E0652.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the chest x-ray rendered on May 12, 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 procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest
x-ray rendered on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Praluent Pen.You asked the Plan to pre-approvethe Praluent. You say that the enrollee has had treatment and failure with other medication in the past with no success.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 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-approvea Praluent Pen.Benefits for the Praluentmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10)months of hemodialysis from September 1, 2020 to June 1, 2021.You asked the Plan to pre-approve ten (10)months of hemodialysis from September 1, 2020 to June 1, 2021.The Plan denied your request. The Plan says the enrollee is required to use network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ten (10) months of hemodialysis from September 1, 2020 to June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable


We decided that the Plan does not have to pre-approvea crown for tooth #7.You asked the Plan to pre-approvethe crown. You say that tooth #7 is broken, and you need it fixed.The Plandenied your request. The Plan says this service is allowed one time every five 60 months. The Plan also says that you last received a crown on tooth #7 less than 60 months ago.Medicare generally does not cover dental services. However, the Plan offersa 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, crowns, bridges, inlay/onlay, and periodontal work may not be providedmore often than once per tooth every five (5) years. The record shows that you received a crown on tooth #7 on July 20, 2017 and your crowns benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea crown for tooth#7.