Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Destruction by neurolytic agent, genicular nerve
branches including imaging guidance, when performed (64624).

You asked the Plan to pre-approve Destruction by neurolytic agent, genicular nerve branches including
imaging guidance, when performed (64624). You say that the enrollee has failed conservative therapy. The
Plan denied your request. The Plan says there is no proof that this procedure improves health or function.

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 Destruction by neurolytic agent,
genicular nerve branches including imaging guidance, when performed (64624). Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is considered an experimental/ investigational procedure at the current time. The role of this
procedure in the management of knee arthritis is still being studied. Therefore, the request is considered not
medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Destruction by neurolytic agent, genicular nerve branches including imaging
guidance, when performed (64624) have not been met. Therefore, we decided that the Plan does not have to
pre-approve Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when
performed (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal treatment (D3346).

You asked the Plan to pre-approve the root canal treatment. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit.

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 pre-approve a root canal treatment (D3346).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and attachments for the enrollee.

You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your
request. The Plan says that Medicare does not cover durable medical equipment (DME) in a skilled nursing
facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that these items is being requested for use in a SNF or hospital. Therefore, we decided that the
Plan does not have to pre-approve a power wheelchair and attachments for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Prolia is covered when medically necessary for Treatment of Bone Loss in Men Receiving Androgen Deprivation Therapy for non-metastatic prostate cancer. 

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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved drug compendia, there is no documentation that the requested Prolia is medically necessary in the setting of prostate cancer that is metastatic to bone. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture.

You asked the Plan to pay for the complete mandibular denture. The Plan denied your request. The Plan says this service is only covered 1 time in a 60 month time period. The Plan also says that you have already had this service done in that time period.

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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a complete mandibular denture and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you are low income and only receive Social Security. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal mouth guard (D9944).

You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says this service is not covered.

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 pre-approve an occlusal mouth guard (D9944).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you no longer require skilled services and the continuation of SNF is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found, you require custodial 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 SNF care have not been met. Specifically, the services you require are custodial, which are not covered benefits under your plan. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested services. You say that the enrollee has not been able to check her blood sugar. The Plan denied your request. The Plan says six months are approved for medical necessity.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The file shows that the plan has pre-approved 6 months of use for a continuous glucose monitor. Every six months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. Therefore, we decided that the Plan does not have to pre-approve additional coverage of a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.

You asked the Plan to pay for psychiatric evaluation. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.

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 psychiatric evaluation was not filed until August 27, 2020. 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 a psychiatric diagnostic evaluation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charges for physical therapy services (97110, 97150, 97161, 97140).

You asked the Plan to waive the deductible charges for physical therapy. You say that you were told by the provider that you would not have to pay. The Plan denied your request. The Plan says your deductible is $750. Until you have paid the deductible amount, you must pay the full cost of your covered services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a deductible of $750 for outpatient rehabilitation services.

The item or service you asked the Plan to pay for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a deductible of $750 for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received. Therefore, we decided that the Plan does not have to waive the deductible charges for physical therapy services (97110, 97150, 97161, 97140).

Your complaint about the potential misinformation you received 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the suspension sleeve for lower extremity orthosis (L2397)
and knee orthosis, adjustable knee joints (L1833).

You asked the Plan to pay for the suspension sleeve for lower extremity orthosis and knee orthosis, adjustable
knee joints. You say that the services were medically necessary. The Plan denied your request. The Plan says
there is no indication the prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that this orthosis is covered if the beneficiary has had
recent injury to or a surgical procedure on the knee or joint laxity.

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 pay for the suspension sleeve for lower extremity
orthosis and knee orthosis, adjustable knee joints. Our reviewer says that the services were not medically
reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination
of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item
coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 suspension sleeve for lower extremity orthosis and knee orthosis, adjustable
knee joints have not been met. Therefore, we decided that the Plan does not have to pay for the suspension
sleeve for lower extremity orthosis (L2397) and knee orthosis, adjustable knee joints (L1833).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan.

You asked the Plan to pre-approve extremity study, duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970). You say that the enrollee needs a duplex scan. The Plan denied your request. The Plan says the records do not show that the enrollee has signs of vein disease in the legs.

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 extremity study, duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records there is no documented lower extremity edema and no documented lower extremity abnormalities suspicious for venous insufficiency. The records therefore do not support the medical necessity for a lower extremity venous ultrasound. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extremity study, duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (93970) have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.


You asked the Plan to pay for the ambulance services. You say that you fell and the medics helped you up and back into bed. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a step stool (E1399).

You asked the Plan to pre-approve a step stool. You say that you need this service to get safely in and out of bed. The Plan denied your request. The Plan says this service is not medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a step stool (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Endovascular Revascularization of the Lower Extremities.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no documented non-healing leg wounds/ulcers or leg gangrene.

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 requested services are not considered medically reasonable and necessary in this case. You present with severe leg pain without characteristics of claudication. When you were last evaluated for severe leg pain, severe enough to require narcotic pain medication, your noninvasive lower extremity arterial studies were normal. On the most recent evaluation you continue to have palpable pedal pulses. You have numerous other coexisting factors that may be responsible for leg pain including a history of sciatica and arthritis. It is noted that you have not had your back imaged yet. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Endovascular Revascularization of the Lower Extremities.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug infusion services (62369, J3490) provided by an out of network (OON) provider.

You asked the Plan to pay for OON drug infusion services. You say that these services are supported by the records. The Plan denied your request. The Plan says these services were not authorized.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug infusion services (62369, J3490) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX melanoma test provided to the enrollee.

You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says the records show a T3b tumor.

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 pay for the test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the biopsy showed at least T3b malignant melanoma with broad ulceration and a Breslow depth of at least 3.7 mm. An order for DecisionDX-Melanoma was made. This test, however, is designed for assisting with treatment and monitoring of melanoma when biopsy shows evidence of T1 or T2 tumors. When more progress such as in the case of this enrollee, the value of this test is not there and it is not appropriate as aggressive treatment is already warranted for this enrollee. Therefore, the DecisionDX-Melanoma will be considered 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 the test have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDX melanoma test provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol HCL for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 Tramadol HCL for the enrollee.

Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cardiology office visit (99215) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON cardiology office visit. You say that your previous insurance covered this doctor and you would like to continue seeing them. The Plan denied your request. The Plan says the requested service is available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the cardiology office visit (99215) to be provided by an out of network (OON) provider.