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

We decided that the Plan does not have to pre-approve use of implanted testosterone pellet (Testopel).
You asked the Plan to pre-approve Testopel. You say that this drug was approved in the past and you have been without the treatment since February 2021. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the records do not indicate that the requested treatment is medically necessary or that you have a significant contraindication to the Plan's preferred preparation of testosterone.
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 pre-approve Testopel. Our reviewer says that you do not meet the Medicare criteria for the requested use of Testopel. Our physician reviewer found Testopel is approved and indicated for hypogonadism in males. However, in this case the criteria for diagnosis of male hypogonadism as established by the National Endocrine Society have not been met. Specifically, you must have symptoms of hypogonadism and biochemical confirmation with 2 low pre-treatment total testosterone levels. Your pre-treatment testosterone levels in the medical records were within normal range. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have to pre-approve use of implanted testosterone pellet (Testopel).
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is at his baseline level of function and does not need skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 from a nursing perspective, the enrollee received oral medications and had stable vital signs. He tolerated a pureed diet and nectar thickened liquids. He was alert with confusion. He received a dose of Rocephin for an elevated white blood cell count. He had uncomplicated dressings to his buttocks/sacrum. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. By the dates in question, the beneficiary was at a minimal assist level with functional mobility including gait to 75 feet with a rolling walker. The beneficiary required varying assist with activities of daily living. The enrollee does not have identifiable skilled nursing or therapy needs. 

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. 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 shoe lift (L3310).
You asked the Plan to pre-approve a shoe lift. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve a shoe lift (L3310).
Appeal type: Practitioner Services
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 aide services so you can go home and have assistance with ADLs. The Plan denied your request. The Plan says there are no skilled needs identified and no doctor order for these 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 looked at 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health skilled nursing visits.
You asked the Plan to pre-approve 8 home health skilled nursing visits. You say that the requested 8 home health skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the requested 8 home health skilled nursing visits are not medically necessary.
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 8 home health skilled nursing visits. Our reviewer says that the requested 8 home health skilled nursing visits are not medically necessary. Our physician reviewer found in this case; the documentation does not support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The wound care is not complex in nature. The member and her caregiver have been taught to perform the wound care. There are no other skilled nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services.

You asked the Plan to reimburse you for the dental services. You say that you called to inform the plan of the treatment of a dental infection that you contracted. You say that you were given an appointment. You say that you had a family emergency and had to go outside the United States. You say that you were due to come home, but due to COVID-19 you were not able to return home. You also say that you were treated for the injection as an emergency. The Plan denied your request. The Plan says the provider in this case is not in the Plan's network. The Plan also says that you must use network providers to receive dental services.

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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 portable oxygen concentrators.
You asked the Plan to pre-approve 2 portable oxygen concentrators. You say that you need this for your
medical condition. The Plan denied your request. The Plan says it is not medically necessary for you to have
two portable oxygen concentrators.
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 Plan has approved 1 portable oxygen concentrator. This portable oxygen concentrator
that the Plan approved serves the same purpose as 2 portable oxygen concentrators. Therefore, we decided that
the Plan does not have to pre-approve 2 portable oxygen concentrators.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connector (E2311) for a power wheelchair.

You asked the Plan to pre-approve the electronic connector. You say that the feature 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 wheelchair features are covered when 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 electronic connector. Our reviewer says that the requested wheelchair feature is not medically necessary. Our physician reviewer found the provided records do not support that the enrollee needs to control the power features from the joystick, therefore the requested connector 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 the electronic connector have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connector (E2311) for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scans of the lower extremity.

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 the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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
pay for the computed tomography (CT) scans of the lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown, prefabricated post and core in addition to a crown, endodontic therapy of an anterior tooth, and endodontic therapy of a premolar tooth.

You asked the Plan to pre-approve the crown, prefabricated post and core, and endodontic therapies. You say that you need these services. The Plan denied your request. The Plan says your plan does not cover these procedures.

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 crown, prefabricated post and core in addition to a crown, endodontic therapy of an anterior tooth, and endodontic therapy of a premolar tooth.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G2024, U0003) provided October 2, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 code G2024, U0003 is not supported in the medical record. Specifically, lab results were not provided for the dates of service at issue. Additionally, the record shows no evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G2024, U0003) provided October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel services coded R0070.

You asked the Plan to pay for the transportation of portable x-ray equipment and personnel 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.

In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.

We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3. As CPT code R0070 is a technical component only code, it should be reported on a hospital setting. The enrollee was in a Skilled Nursing facility setting; therefore, we find the Medicare rule for payment of this claim has not been met. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel services coded R0070.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 laboratory testing provided on November 12, 2020.
You asked the Plan to pay for the laboratory testing. You say that the provider is an independent laboratory servicing nationwide. You say that you had no knowledge of the enrollee's coverage prior to the specimen's arrival to the laboratory. You say that the lab should not be penalized for being out of network as you continue to provide timely testing and results during the Covid-19 pandemic. You also say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Covid-19 laboratory testing provided on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. 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 medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 pre-approve Opdivo. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has small cell lung cancer. The enrollee is intolerant to Tecentriq. The documentation does not support that the requested drug is FDA-approved for the enrollee's diagnosis. Opdivo indication for small cell cancer has been removed. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services.

You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were not billed with the appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay.

We looked at the file and Medicare rules. The services in question were not billed modifier -26 to indicate the professional component of the imaging. Without the use of this modifier, the requested imaging services cannot be paid. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no existing evidence to support the use of this device to treat low back pain.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152.

You asked the Plan to pay for the moderate sedation 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 supported by the documentation.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this device exceeds the enrollee's needs.

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. The requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 a MyoPro Motion G Orthotic device for the enrollee.