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

We decided that the Plan does not have to pre-approve proton beam therapy treatments for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the outcome with proton therapy is better than conventional radiation treatments. The Plan denied your request. The Plan says proton beam therapy has not been proven to offer advantages over highly conformal radiation therapy, such as intensity-modulated radiation therapy (IMRT).
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 requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. There is no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Therefore, the requested services are not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy treatments for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0160), the amalgam filling (D2150), and the pulpal debridement (D3221) provided on August 15, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the services that were provided to the enrollee were dental in nature. The Plan says that the dental services are not covered under the enrollee's medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral exam (D0160), the amalgam filling (D2150), and the pulpal debridement (D3221) provided on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp, 300 mcg.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says Aranesp is a non-preferred drug. The Plan says that Retacrit, the approved drug, has been approved for 6 months starting March 17, 2020. The Plan also says that if the prescriber uses the preferred drug, it will be covered.
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 criteria coverage has not been met. Our physician reviewer found the documentation provided does not show that the enrollee has previously tried and failed the required drug, Retacrit. The documentation also does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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-approve Aranesp, 300 mcg.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT Scan and MRI provided on September 10, 2019 through September 11, 2019.
You asked the Plan to pay for the CT Scan and MRI. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that these services were denied because you did not obtain prior authorization.
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 did not forward the Evidence of Coverage to indicate the contract rules in regards to prior authorization for these services. The Plan also did not forward a denial in regards to the services which were rendered on September 11, 2019. There is insufficient information to substantiate the Plan's denial. Therefore, we decided that the Plan has to pay for a CT Scan and MRI provided on September 10, 2019 through September 11, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS) treatments.
You asked the Plan to pre-approve the PTNS treatments. You say that it is felt this is medically necessary as the enrollee has tried multiple treatments and cannot use another anti-cholinergics due to salivary gland issues. The Plan denied your request. The Plan says there is no evidence that there was any medical management tried for the enrollee's dry mouth and no evidence that two different drugs were tried and failed.
The Plan follows Medicare rules. Medicare rules say that PTNS may be covered for OAB when there is a documented failure of a four-week trial of two anticholinergic drugs or clear intolerance with evidence that medical management was tried for common side effects. 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 PTNS treatments. Our reviewer says that the requested PTNS treatment is not considered reasonable and necessary due to LCD criteria not being met. Our physician reviewer found the enrollee is a male with history of prostate cancer treated with radical prostatectomy in 2008. He was treated for a UTI in 10/19 and developed frequency, urgency and urge incontinence. He was treated with Myrbetriq and initially had good results but the urgency and urge incontinence recurred 2/6/20. Coverage criteria have not been met. The medical records provided do not indicate that the patient has tried and failed or was intolerant to 2 anticholinergic drugs, each taken for at least 4-weeks duration. 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 PTNS treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that hearing aids are necessary as you have been diagnosed with inner ear nerve damage and have experienced hearing loss. The Plan denied your request. The Plan says hearing aids are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate for you in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin extended-release tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Metformin extended-release tablets.
Benefits for self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for a power scooter (K0739, E2368, K0108, E0971).
You asked the Plan to pre-approve the repairs. You say that the repairs are medically necessary. The Plan denied your request. The Plan says the record does not show that the power scooter is still medically necessary, so the repairs cannot be covered.
The Plan follows Medicare rules. Medicare rules say that repairs for Durable Medical Equipment can only be covered when the record shows the wheelchair or other equipment continues to be 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 repairs. Our reviewer says that a scooter repair is not medically necessary as the documentation does not support that the scooter requested to be repaired continues to be medically necessary. Our physician reviewer found the documentation does not indicate that the patient requires the mobility device to perform activities of daily living in the home. There is no evidence that the patient is unable to relieve her mobility deficit in the home with a walker or manual wheelchair. There are no measurements in the home that indicate that this patient can safely navigate the device in the home. 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 repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs for a power scooter (K0739, E2368, K0108, E0971).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on October 25, 2019 by an out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to continue oxygen services with you. The Plan denied your request. The Plan says current office notes do not show evidence of medical necessity for oxygen and you did not request prior authorization.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Current medical records do not support medical necessity for the oxygen concentrator. 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 oxygen services provided on October 25, 2019 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar 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 medical studies have not proven that this device is helpful for treatment of this health problem.
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental, and more research is needed. 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 an interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on September 13, 2019 to September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you have submitted medical records for review. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says routine services were provided. The Plan says that these services could be provided in-network. The Plan says that no prior authorization was obtained.
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 has network providers available who can provide 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 an office visit and physician services provided on September 13, 2019 to September 16, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat tablets.
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 self-administered drugs are not covered.
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 Febuxostat tablets.
Benefits for these services 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: 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from May 4, 2019 through May 5, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.
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. The enrollee was enrolled in hospice from April 16, 2019 through May 6, 2019. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from May 4, 2019 through May 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services (CPT 64999) provided to the enrollee on October 29, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 64999-50 remains not supported, as the submitted procedure note did not indicate the name of the unlisted procedure that was performed.
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 64999 is "Unlisted procedure, nervous system." 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 services. Our reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the documentation describes injections to hardware at four different sites. The documentation does not note injections to joints or spaces, which would be better attributed by more specific billing codes. The documentation supports the code as billed. 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 services have been met. Therefore, we decided that the Plan has to pay for physician services (CPT 64999) provided to the enrollee on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening you received on October 26, 2019. 
 
You asked the Plan to pay for the screening. You say that this should be covered. The Plan denied your request. The Plan says you were advised this would not be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare generally does not cover screening services, which are defined as examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.  
 
The documentation indicates that you have a history of prostate cancer. PSA testing for those with a history of prostate cancer is not covered as annual screening as it is being performed in relationship to diagnosis of a specific illness. It appears that this service was requested during evaluation for a non-related condition and that you were informed it would not be covered. There is no evidence that this was ordered by a provider who is fully knowledgeable about your condition who would be responsible for explaining the results. As such, we find that the conditions for payment for a screening PSA test have not been met in this case. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening you received on October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you have not tried 2 different medications or behavioral treatments.
The Plan follows Medicare rules. Medicare rules say that PTNS is only covered under certain medical indications. 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 requested services. Our physician reviewer found that you have a history of superficial bladder cancer, and underwent trans-urethral resection of bladder tumor. You presented with complaints of dysuria and urgency. You were prescribed Bactrim and given samples of Myrbetriq 50 mg. The records provided do not indicate any other treatments for overactive bladder were tried or prescribed. Therefore, the services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transthoracic Echocardiogram.
You asked the Plan to pre-approve a Transthoracic Echocardiogram. You say that you need this due to your heart complications. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a Transthoracic Echocardiogram is covered only for the above listed indications. Screening Transthoracic Echocardiograms 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 a Transthoracic Echocardiogram. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found you have no documented heart disease, no documented symptoms for an acute cardiac condition, and no documented abnormal cardiovascular or pulmonary physical exam findings. The documentation does not support the medical necessity for echocardiography. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Transthoracic Echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transthoracic Echocardiogram.