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

We decided that the Plan has to pre-approve a facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested procedure is supported for predominantly axial pain that is not associated with radiculopathy.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 injection. Our reviewer says that the requested injection is considered medically reasonable and necessary in this case. Our physician reviewer found the pain complaints and exam match a facet pathology. The request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve a facet joint injection for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on July 30, 2020.You asked the Plan to pay forthese 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 previouslypaid 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 forthe surgical services rendered on July 30, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp.You asked the Plan to pre-approveAranesp. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Aranesp. Our reviewer says that the requirements for coverage of Aranesp have not been met. Our physician reviewer found the Plan requires a trial of Retacrit (epoetin alfa) before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicatingthat the Plan's required drug would likely be less effective or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeyeglasses.You asked the Plan to pre-approveeyeglasses. You say that you believe your eyeglasses were stolen and you need another pair of eyeglasses.The Plan denied your request. The Plan says the eyewear allowance is an annual benefit, and you received coverage for eyeglasses on February 26, 2021.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that you received the annual eyewear allowance benefit on February 26, 2021. Therefore, we decided that the Plan does not have to pre-approveeyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines state that there must glucose level testing at least four or more times per day.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria requires that the enrollee be checking blood glucose levels four times a day, and be taking insulin shots three times a day. This has not been demonstrated in the records.

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dialysis services. You say that you do not understand why this facility is OON. The Plan denied your request. The Plan says they have in-network providers within the enrollee's service area able to provide for your medical needs.
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 dialysis services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental code D3320.

You asked the Plan to pre-approve dental code D3320. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D3320 is not covered under the Plan's supplemental dental 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 dental services with dental code D3320.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 23, 2020.

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 was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 8, 2021.

You asked the Plan to pay for the extraction. You say that the Plan should pay for the extraction because you had an emergency with a broken tooth.The Plan denied your request. The Plan says extractions are not covered under your supplemental 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 pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are in need of rehab and were unable to complete it at the time.The Plan denied your request. The Plan says the stay is not medically necessary.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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for right sided weakness. Medical conditions are stable.There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit fromthe 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the electroencephalogram provided on January 8, 2021.
You asked the Plan to pay for electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) (95718). You say that the procedure is not experimental and investigational. The Plan denied your request. The Plan says that that they failed to address the appellants entire appeal request.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We looked at the file and Medicare rules. The diagnosis code G93.40 Encephalopathy is a covered diagnosis. This procedure is covered and not considered experimental. Based on this information, we decided that Medicare rules for coverage of electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) (95718) have been met. Therefore, we decided that the Plan has to pay for the electroencephalogram provided on January 8, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided on August 14, 2020.
You asked the Plan to pay for a crown. You say that you had this service done by another provider and it should not have fractured so soon. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of once per tooth every 5 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 crown have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 7, 2019. Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 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 the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an external infusion pump (E0784).
You asked the Plan to pre-approve an external infusion pump (E0784). You say that the requested external infusion pump (E0784) is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested external infusion pump (E0784). The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an external infusion pump (E0784). Our reviewer says that the requested external infusion pump (E0784) is medically necessary. Our physician reviewer found the enrollee is with diabetes mellitus and labs in November 2018 show creatinine at 0.9 and glucose at 154 and c-peptide less than 01.0 indicating insulinopenia. She is taking 5 shots of insulin per day and checking blood glucose levels 4 times per day according to logs submitted; she has erratic blood glucose levels and a1c of 7.3. She has insulinopenia by lab values and is on 5 shots per day of insulin and meets the criteria for pump coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external infusion pump (E0784) have been met. Therefore, we decided that the Plan has to pre-approve an external infusion pump (E0784).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services to be provided by a provider not enrolled in the Medicare program.You asked the Plan to pay foroutpatient mental health services. You say that the requested services are a necessity for you.The Plan denied your request. The Plan says rules for Medicare coverage have not been 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 foroutpatient mental health services to be provided by a provider not enrolled in the Medicare program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean automatic blood pressure monitor.You asked the Plan to pre-approvethe automatic blood pressure monitor. You say that the medical records provided support the need for the requested device.The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approvean automatic blood pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 heavy duty power wheelchair and batteries for the enrollee.You asked the Plan to pre-approvea Group 2 heavy duty power wheelchair and batteries. You say that this would greatly improve the enrollee's independence, safety and medical necessity of getting to the bathroom.The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for approval.The Plan must follow Medicare rules. Medicare rules say that a Group 2 power wheelchair can be covered if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces forthe operation of the POV that is provided. We looked at the file and Medicare rules. The Seating and Mobility Evaluation provided indicates that the enrollee's kitchen and bathroom doors are too narrow for the requested power wheelchair. Based on this information, we decided that Medicare rules for coverage of a Group 2 heavy duty power wheelchair and batteries have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 heavy duty power wheelchair and batteries for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that Medicare does not consider this feature to be primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approveapower seat elevation feature (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee has an unsteady gait which makes it difficult to stand. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on January 8, 2021.
You asked the Plan to pay for the PET/CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. We find that the PET/CT scan is not supported as billed. Specifically, this PET/CT scan was not billed with an appropriate diagnosis code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on January 8, 2021.