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

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
You asked the Plan to pre-approve genetic tests. You say that you have a family history of cancer and this would be clinically beneficial to you. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these tests are being requested for screening purposes which is 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 tests at issue in this appeal, genetic tests, are being requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone gel 1% (50ml).
You asked the Plan to pre-approve the gel. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit.
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-approve Testosterone gel 1% (50ml).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - porcelain fused to high noble metal [A custom made tooth-shaped covering that fits tightly over a tooth to replace structure damaged by decay or trauma. It is made out of porcelain and metal.] tooth #8 and #9 (D2750) provided on November 25, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is 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. 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for crown - porcelain fused to high noble metal [A custom made tooth-shaped covering that fits tightly over a tooth to replace structure damaged by decay or trauma. It is made out of porcelain and metal.] tooth #8 and #9 (D2750) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a power operated vehicle. You say that you need a scooter so you can leave your home and run errands. The Plan denied your request. The Plan says your assessment shows you can walk with use of your walker and have the strength to use a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Also, the scooter at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495).You asked the Plan to pre-approve facet joint injections. You say that these services are medically necessary.The Plan denied your request. The Plan says the enrollee has radicular pain for which facet joint injections are not indicated.The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when there is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, infection or significant deformity. 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 facet joint injections. Our reviewer says that the requested injections are not medically necessary at this time. Our physician reviewer found the enrollee's physical exam does not support the facets as the source of her pain and she has other degenerative disc changes that can be the source of her back pain.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on September 5, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a critical care progress note for the billed date of service.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does not include a critical care progress note. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and a diagnostic dental procedure provided on November 4, 2019.
You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and a diagnostic dental procedure. You say that the provider's dental assistant told you that the treatment would be covered, in full, by your Plan. You also say that you are on Social Security and live on a very tight budget and cannot afford expensive dental treatments. The Plan denied your request. The Plan says these 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and a diagnostic dental procedure provided on November 4, 2019.
Your complaint about being misinformed by the dental assistant is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve facioscapulohumeral muscular dystrophy (FSHD) genetic testing.
You asked the Plan to pre-approve FSHD testing. You say that you do not have a diagnosis, and there is no way to make a positive diagnosis without this testing. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this test is not medically necessary and is unlikely to impact therapeutic decision-making for the enrollee.
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 FSHD testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the requested testing is readily consistent with current professional society guidelines and would be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition. While no disease-modifying treatment is currently available, the enrollee in this case cannot be properly managed without a definitive diagnosis. The management of this enrollee could include interventions such as physical therapy, exercise, pain control, and orthopaedic consultation. In addition, the enrollee would be at risk for pulmonary, ophthalmologic, and auditory complications related to FSHD, and would benefit from surveillance of these organ systems. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FSHD testing have been met. Therefore, we decided that the Plan has to pre-approve facioscapulohumeral muscular dystrophy (FSHD) genetic testing.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical microdiscectomy for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that any alternative treatments have been tried.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for surgery is not met. There is no recent trial of physical therapy. There is no evidence of severe canal stenosis on MRI. The EMG shows carpal tunnel condition. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical microdiscectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical/thoracic facet joint block injection.
You asked the Plan to pre-approve the injection. 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 injection.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you failed to achieve 80% pain relief, as required by the LCD. Therefore the request is not deemed to be 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical/thoracic facet joint block injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says if there is a certain service that is not available within the network of providers, prior authorization is required.
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 physician's services. 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 physician's services provided on May 28, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve implantation 
You asked the Plan to pre-approve implantation You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are 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 implantation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have severe obstructive sleep apnea. You have failed CPAP therapy. The requested services are being used as salvage therapy for you who have failed conventional therapy. Therefore, you meet criteria for the requested services.
Review of the file shows that the plan uses LCD DL38528 to support their denial. However, LCD DL38528 is not in effect. Therefore, we cannot use DL38528 to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantationhave been met. Therefore, we decided that the Plan has to pre-approve implantation
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on November 3, 2018.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says you submitted the claim 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 services was not filed until December 30, 2019. 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 services provided to the enrollee on November 3, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePraluent.You asked the Plan to pre-approvePraluent. 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 a covered benefit.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-approvePraluent.Benefits for 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear providedon October 3, 2019.You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says your benefit maximum has been met.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.We looked at thefile and the Plan's rules. The file shows that you received the routine eyewear benefit on October 11, 2017 and you were not eligible to receive the benefit until October 11, 2019. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay fortheeyewearprovided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging and a stress test provided on May 13, 2019, and anesthesia services provided on October 30, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging, a stress test, and anesthesia services. You say that you should not owe money for these services. The Plan denied your request. The Plan says these services processed 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 $150 copayment for diagnostic radiology, a $50 copayment for non-radiological diagnostic tests, and a $325 copayment for outpatient hospital services. You have been asked to pay $150 for myocardial perfusion imaging, a diagnostic radiology service; $50 for a stress test, a non-radiological diagnostic test; and $84 for anesthesia services, which were outpatient hospital services, but had an allowed amount lower than the listed copayment. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the surgical services you received on June 19, 2019, and November 18, 2019.You asked the Plan to waivethe copayment. The Plan denied your request. The Plan says you are responsible for the cost share.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 contractwith the Plan clearly says that you must pay a $500 copayment for per visit for outpatient surgery. Review of the file shows that you were provided surgical services on June 19, 2019, and November 18, 2019. You have been asked to pay a $500 copayment for each of the services. The services fall within the outpatient surgery 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 waivethe copayment for the surgical services you received on June 19, 2019, and November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 3 wheelchair and accessories.You asked the Plan to pre-approvea group 3 wheelchair and accessories. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea group 3 wheelchair and accessories.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from June 11, 2019 to June 13, 2019.
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 the plan is upholding the claim denial as the billed claim is for a nonparticipating Home Health provider and a required TAC code was not included in box 63 of the claim. The TAC code is a required data element on HH PPS claims for research and payment calculations therefore we find the Medicare rule for payment of this June 11, 2019 through June 13, 2019 claim has not been met the required criteria. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment
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 is [*****enter CPT Codebook definition*****]. We find that CPT code is not supported in the medical record. Specifically [*****explain why code billed is not supported******]. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from June 11, 2019 to June 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 8, 2019.
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 the physician documentation provided does not support the services billed, nor does it meet the Medicare coverage criteria for the documentation expected.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for definitive drug testing. Medicare rules say that physicians and providers must produce medical records showing why the lab services provided were medically necessary. In this case, there were insufficient records provided to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes and when multiple tests are done at one time. The physician order provided does not meet these criteria. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on July 8, 2019.