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

We decided that the Plan does not have to pre-approve use of Gel-One viscosupplementation.
You asked the Plan to pre-approve Gel-One. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee had a corticosteroid injection but there has not been adequate follow-up to determine if it was effective.
The Plan follows Medicare rules. Medicare rules state that hyaluronan acid therapies for osteoarthritis of the knee may be covered under certain clinical conditions. 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 Gel-One. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Gel-One. Our physician reviewer found there needs to be documentation of the enrollee's clinical response to knee steroid injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Gel-One viscosupplementation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 find that CPT codes 80053, 82495, 82533, 82607, 82627, 82670, 82728, 82746, 82977, 83036, 83090, 83615, 83655, 83825, 84144, 84202, 84270, 84403, 84439, 84443, 84481, 84550, 85025, 86141, and 86328 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates
the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you need help around the house.
The Plan denied your request. The Plan says you do not need skilled services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our
reviewer says that the requirements for coverage of a home health aide have not been met. Our physician
reviewer found there is no evidence that you require or are receiving skilled nursing or rehabilitative services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace provided on April 13, 2021.
You asked the Plan to pay for the back brace. You say that this is medically necessary and was ordered after a telehealth consultation. The Plan denied your request. The Plan says the criteria for coverage of this brace are not met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the back brace provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive spine surgery.
You asked the Plan to pre-approve minimally invasive spine surgery. You say that the services are necessary.
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve minimally invasive spine surgery. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the minimally invasive lumbar decompression (MILD) procedure remains
experimental. More research is needed to show safety and efficacy of the procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of minimally invasive spine surgery have not been met. Therefore, we decided that
the Plan does not have to pre-approve minimally invasive spine surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 22, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that the services at issue should be covered. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on July
10, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for dental services (D0274, D0220, D0230, D0120 and D1110) provided
on January 7, 2020.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because this
dentist is in-network. The Plan denied your request. The Plan says that supplemental dental services must be
received from a participating provider in order to be covered.
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 has failed to verify the network status of the treating dentist. There is
conflicting information in the case file regarding network status. Please note, we have requested this
information from the Plan without response. It is the responsibility of the Plan to substantiate their denial with
evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the
Plan has to pay for dental services (D0274, D0220, D0230, D0120 and D1110) provided on January 7, 2020.
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 pay for cervical or thoracic facet joint injections (64634) provided on August 25, 2020.
You asked the Plan to pay for cervical or thoracic facet joint injections. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed without an appropriate primary code.
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 64634 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure).
We find that CPT code 64634 is not supported in the medical record. Specifically, this is an add-on code that was not billed with the appropriate primary procedure (64633). Based on this information, we decided that Medicare rules for coverage of cervical or thoracic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for cervical or thoracic facet joint injections (64634) provided on August 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 home health aide services.. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you are not homebound. Home health services are not covered by Medicare for enrollees who are not homebound. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic axial low back
pain. The requested Intracept procedure remains experimental for the treatment of low back pain. More
research is needed to show safety and efficacy for the procedure. The services are therefore not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acyclovir 5% ointment.
You asked the Plan to pre-approve the Acyclovir 5% ointment. The Plan denied your request. The Plan says this drug is not covered for your 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-approve Acyclovir 5% ointment.
Benefits for the Acyclovir 5% ointment 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: Drugs
Decision: Favorable

We decided that the Plan has to waive the copayment for the home infusion services provided from January 21, 2021, through January 28, 2021.
You asked the Plan to waive the copayment for the home infusion services. You say that the infusion therapy was self-administered and there were no services provided by a medical professional. You say that you believe the charges are fraudulent because the charge is for a service provided and not medicine or supplies. The Plan denied your request. The Plan says that the copayments applied correctly.
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 records do not support that a service was provided by a physician to bill for home infusion services. Therefore, we decided that the Plan has to waive the copayment for the home infusion services provided from January 21, 2021, through January 28, 2021.
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: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services (71045) provided on October 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the diagnosis code
criteria are not met.
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 documentation submitted by the Plan does not support that the diagnosis
code criteria are not met. The services were billed with multiple diagnosis codes and only one code (I70.90) is
mentioned in the applicable LCA. As such, the Plan's denial cannot be substantiated. Therefore, we decided
that the Plan has to pay for the services (71045) provided on October 31, 2020.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 12, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot breathe and have COPD. You say that you are at high risk. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for bronchoscopy because of an aspirated foreign body. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to provide a Botox injection.
You asked the Plan to provide injection, onabotulinumtoxina, 1 unit (J0585) and Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) (64615). You say that Botox treatments will be beneficial for the enrollee's chronic migraine headaches. The Plan denied your request. The Plan says that the enrollee does not meet the requirements.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 provide injection, onabotulinumtoxina, 1 unit (J0585) and Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) (64615). Our reviewer says that Botox is medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of chronic migraine without aura, not intractable, without status migrainosus, as well as right temporomandibular joint (TMJ) dysfunction and chronic pain. On July 19, 2021 it is documented that the enrollee was referred for neurotoxin treatments to manage her chronic TMJ dysfunction. It is also documented that the enrollee reported 15 or more headaches per month, each lasting longer than 4 hours, sometimes lasting all day. Sumatriptan did not help, and Toprmax gave her adverse reaction. All of these were tried for at least 6 months. Botox is FDA-approved for the prophylaxis of chronic migraine. LCD L33646 states that coverage will be allowed for patients with chronic daily headaches which may be chronic migraine, occurring greater than 15 days a month for a period of at least 3 months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection, onabotulinumtoxina, 1 unit (J0585) and Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) (64615) have been met. Therefore, we decided that the Plan has to provide a Botox injection.
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