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

We decided that the Plan has to pre-approve breast reconstruction (19342 and 19316).You asked the Plan to pre-approve breast reconstruction. You say that this is necessary due to pain and lipedema.The Plan denied your request. The Plan says that that this is cosmetic.The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is 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 breast reconstruction. Our reviewer says that the requested surgery is medically necessary. Our physician reviewer found you have undergone medically necessary bilateral mastectomy followed by typical breast reconstruction due a left breast cancer. Based on the most recent evaluation, you have evidence of typical complications and deformities related to your medically necessary breast reconstruction. You have significant breast asymmetry, which should be considered an abnormal appearance. The planned procedures for revision are consistent with standard procedures and standard of care. You have common complications associated with reconstructive breast surgery. Cosmetic surgery is aimed at improving on normal structures. You have evidence of abnormal bilateral breasts as a result of a previously, severely deforming mastectomy and attempted breast reconstruction that is currently complicated by multiple deformities. This is reconstructive surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Breast reconstruction is done to approximate a normal appearance and this should include complications related to breast reconstruction.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reconstruction have been met.Therefore, we decided that the Plan has to pre-approve breast reconstruction (19342 and 19316).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: Unfavorable

We decided that the Plan does not have to waive the copayments for the podiatry visits, the specialist office visit, or the pacemaker check provided from September 20, 2019 to November 8, 2019.
You asked the Plan to waive the copayments for the podiatry visits, the specialist office visit, and the pacemaker check. You say that you were told you would not have any copayments. 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 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 $35 copayment for each Medicare-covered podiatry service, a $35 copayment for specialist services (including surgery second opinion and telehealth or urgently needed services) and a $5 copayment for diagnostic procedures and tests. You have been asked to pay a total of $205.53 for the podiatry visits, the specialist office visit, and the pacemaker check. The podiatry visits fall within the "Podiatry services" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The pacemaker check 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 copayments for the podiatry visits, the specialist office visit, or the pacemaker check provided from September 20, 2019 to November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on July 25, 2019. You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the records do not support medical necessity and the enrollee has knee orthoses still under reasonable useful lifetime. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee already had knee orthoses (L1833) and suspension sleeves (L2397) at the time the knee orthoses (L1833) and suspension sleeves (L2397) was received. The enrollee's knee orthoses (L1833) and suspension sleeves (L2397), received in 2018, serve the same purpose as the knee orthoses (L1833) and suspension sleeves (L2397) at issue. The orthoses are still within the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the knee orthoses at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator for the enrollee.
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says the BiPAP being
currently used was not ruled out as ineffective.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our physician reviewer
found that the enrollee has been on a Trilogy ventilator, AVAPS AE mode, since mid-2019. The enrollee has a
diagnosis of COPD, but there is no documentation of increased pCO2. There are no pulmonary function results.
It appears obesity-hypoventilation syndrome has not been considered. If the enrollee does have chronic
hypercarbic respiratory failure, then it appears BiPAP would meet the respiratory support needs. There is no
evidence of BiPAP failure. Medicare does not cover a home ventilator when used as BiPAP. Therefore, a home
ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Emu 0.05%.
You asked the Plan to pre-approve Restasis Emu 0.05%. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Restasis Emu 0.05%.
Benefits for Restasis Emu 0.05% may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional occupational therapy (OT) sessions.
You asked the Plan to pre-approve 15 additional OT sessions. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 15 additional OT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy of 15 more OT sessions is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior OT therapy visits for a left hand contracture and the documentation does not reveal evidence of significant objective functional improvement from this prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in splinting and staff can provide assist with donning/doffing splinting. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 additional OT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional occupational therapy (OT) sessions.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation services provided on January 7, 2020.You asked the Plan to pay forthe transportation services. You say that you got this Plan because you could get a ride to and from doctor appointments with only paying a small copay.The Plan denied your request. The Plan says you do not have a routine transportation benefit.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of transportation services have not been met.Therefore, we decided that the Plan does not have to pay fortransportation services provided on January 7, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvecomputed tomographic angiography (CTA) services.You asked the Plan to pre-approvethe CTA services. You say that the records provided support the need for a CTA scan.The Plan denied your request. The Plan says that they do not havedoctor notes telling them about the problem, how long the enrollee has had it, and how it is getting worse. The Plan says that there is no information showing if the enrollee has had other tests done.The Plan must follow Medicare rules. Medicare rulessay that CT scans are covered only when they are 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 CTA services. Our reviewer says that the requested CTA services are medically reasonable and necessary. Our physician reviewer found the enrollee has severe aortic valve stenosis and is being considered for TAVR procedure. In this circumstance a pre-TAVR assessment of pelvic and abdominal arterial vessels is standard medical practice and medically necessary to evaluate vessel size and anatomy to see if a percutaneous femoral approach to valve replacement is feasible.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 CTA services have been met.Therefore, we decided that the Plan has to pre-approvecomputed tomographic angiography (CTA) services.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Aer Ellipta.
You asked the Plan to pre-approve Trelegy Aer Ellipta. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Trelegy Aer Ellipta.
Benefits for Trelegy Aer Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaystreatment of the lower back pain caused by a pinched nerve is within the scope of a spine surgery specialist, rather than a general surgery specialist.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 Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, cleaning (D1110) provided November 4, 2019.
You asked the Plan to pay for the dental services. You say that you do not feel that you should have to pay for the cleaning because you are allowed to have 1 cleanings paid for in a benefit year with the plan The Plan denied your request. The Plan says this request exceeds the 2cleaning frequency limitation per benefit year.
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. Records show that this service was provided on April 10, 2019 and July 10, 2019. 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 prophylaxis, cleaning (D1110) provided November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 6, 2019.You asked the Plan to pay for the physician's services. You say that you believed that this provider was in-network and that the Plan had approved these services. The Plan denied your request. The Plan says prior authorization and referral is required for specialist 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 contract with the Plan also says that prior authorization and referral is required for specialist services.The requested provider in this case is not a network provider with the Plan. 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 physician's services provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 300 additional catheters as part of a 3 month supply. You asked the Plan to pre-approve the 300 additional catheters. You say that the requested supplies are medically necessary due to an operation which destroyed the enrollee's nerves and caused her to be unable to expel urine on her own. You say that the doctor notes verify the enrollee's diagnosis and confirms her use of the medical supplies being requested. You say that the enrollee uses intermittent catheters daily. The Plan denied your request. The Plan says the medical records were not sufficient to support the need for the supplies being requested. 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 300 additional catheters. Our reviewer says that the additional catheters being requested are not considered medically reasonable and necessary in this case. Our physician reviewer found urinary retention that is managed with intermittent catheterization. The daily frequency of catheterization was not provided in the medical records. The etiology of the enrollee's urinary retention was not provided, however there is a history of lumbar fusion surgery in 2002 and 2008 and placement of a spinal cord simulator in 2006. The medical records do not explain why 900 catheters every 3 months is needed. The vast majority of patients with urinary retention typically utilize 90-120 catheters per month. 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 300 additional catheters have not been met. Therefore, we decided that the Plan does not have to pre-approve 300 additional catheters as part of a 3 month supply.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 6, 2019, September 13, 2019,
September 20, 2019 and December 6, 2019.
You asked the Plan to pay for the physician's services. You say that you believed that this provider was in-network and that the Plan had approved these services. The Plan denied your request. The Plan says prior authorization and referral is required for specialist 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 contract with the Plan also says that prior authorization and referral is required for specialist services. The requested provider in this case is not a network provider with the Plan. 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 physician's services provided on September 6, 2019, September 13, 2019, September 20, 2019 and December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on September 18, 2019 and billed under code 88321. You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the ZC7 edit shows a duplicate of a charge that was previously processed and paid for code 88321 for this enrollee and date of service. It's not expected this code would be reported more than once per date of service. According to the AMA CPT manual, code 88321 is "Consultation and report on referred slides prepared elsewhere." A unit of service for code 88321 is considered the surgical pathology case or cytopathology case, which can include multiple specimens for review. Therefore, if a single surgical case included multiple specimens for review, the appropriate consultation code would be reported only once for the review of all the specimens in that surgical (or cytopathology) case. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, 88321 was previously reported and paid once for this enrollee. It would not be expected to be billed again per Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on September 18, 2019 and billed under code 88321.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Abdomen (74150).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan
denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 CT scan. Our reviewer says that
coverage criteria has not been met. Our physician reviewer found the enrollee apparently has had mildly
elevated, but improving liver functions tests. There is no documentation of a related history, examination,
differential diagnosis or treatment plan. The documentation does not support that the requested CT scan
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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve Computed Tomography (CT) of the Abdomen (74150).