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

We decided that the Plan does not have to pay for an electrocardiogram (ECG) (CPT 93010) provided to the enrollee on November 20, 2020.
You asked the Plan to pay for the electrocardiogram. You say that this should be paid for. The Plan denied your request. The Plan says there is insufficient information to corroborate the services.
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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only." We asked our coding 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 electrocardiogram. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the emergency room visit does not include documentation of an ECG with at least 12 leads, interpretation, and report. Therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (ECG) (CPT 93010) provided to the enrollee on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740 x 3) and core build up (D2950
x 4).
You asked the Plan to pre-approve the dental services. You say that you have medical conditions. You say that
you need to have this dental work done. The Plan denied your request. The Plan says 1 crown is covered per
year. The Plan says that the frequency limit has been reached. The Plan also says that core build up are not
listed as 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 and crowns are listed as a covered
service, the frequency limit has been reached. The record shows that the Plan approved a crown on March 4,
2020. Additionally, core build up are not among those covered under this benefit. Therefore, we decided that
the Plan does not have to pre-approve porcelain crowns (D2740 x 3) and core build up (D2950 x 4).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a cervical/thoracic interlaminar epidural injection (62321).

You asked the Plan to pre-approve a cervical/thoracic interlaminar epidural injection. You say that after a
follow up discussion with the enrollee yesterday, she has gone to PT twice weekly for 4 weeks and states her
response is limited and feels like she has plateaued. The Plan denied your request. The Plan says that the
information submitted does not support the requirements of medical necessity guidelines.

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 a cervical/thoracic interlaminar epidural
injection. Our reviewer says that the requested items/services are considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee is s/p cervical fusion and has spurring on
MRI. There is no LCD and the enrollee had plateaued in benefit from the 4 weeks of physical therapy. 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 a cervical/thoracic interlaminar epidural injection have been met. Therefore, we
decided that the Plan has to pre-approve a cervical/thoracic interlaminar epidural injection (62321).

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 the pneumatic compressor and appliance to be provided by an out-of-network provider.

You asked the Plan to pre-approve the pneumatic compressor and appliance. You say that there is no other supplier that is able to provide the same prescribed program. You say that the records document a worsening of symptoms and the denial should be reversed. The Plan denied your request. The Plan says in-network providers are available.

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 pneumatic compressor and appliance to be provided by an out-of-network provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level of care.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of
fractures of the hip and wrist after a fall. The enrollee's medical problems are stable. There are no complex
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiation oncology evaluation for proton beam therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says proton beam therapy is not medically necessary.
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 provider at issue in this case is not a network provider with the Plan. 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 this service. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that the American Society of Radiation Oncology does not routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. The Plan has network providers available who can provide the appropriate service to manage your condition. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a radiation oncology evaluation for proton beam therapy to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 monitor. You say that this will help maintain the enrollee's treatment. The Plan denied your request. The Plan says the documentation does not indicate use of insulin.
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 there is no reason given as to why you are unable to use a glucometer to get the same information provided by the requested monitor. 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 a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820).
You asked the Plan to pre-approve the interim partial denture. You say that you believe this service should be covered. 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 interim partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair and skin protection (E2607, K0848).
You asked the Plan to pre-approve the Group 3 Power Wheelchair. You say that you would like reconsideration because you need a power wheelchair. The Plan denied your request. The Plan says you are able to use a power wheelchair in your home to perform mobility related activities of daily living and you do not have a neurological condition, myopathy,or congenital skeletal deformity.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair and skin protection (E2607, K0848).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coronary computed tomography angiography (CCTA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CCTA is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has an elevated calcium score and risk factors for cardiovascular disease. There are reportedly some non-specific T wave changes on a resting electrocardiogram (EKG), but no cardiac clinical symptoms of any kind at present. In the absence of symptoms of coronary artery disease (CAD) and with an interpretable EKG (if stress testing is indicated) and no suspicion of cardiac structural abnormalities, the CCTA is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve coronary computed tomography angiography (CCTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS unit for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered for chronic low back
pain with enrollment in an approved clinical study.
There is no evidence of enrollment in a clinical study. Based on this information, we decided that Medicare
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to preapprove
a TENS unit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional bedside drainage bags.

You asked the Plan to pre-approve the additional items. The Plan denied your request. The Plan says additional bags are not necessary.

The Plan must follow Medicare rules. Medicare rules say that additional charges will be allowed for reasonable and necessary non-routine changes when the documentation substantiates the medical necessity

We looked at the file and Medicare rules. In this case, there are insufficient medical records to show additional bags are medically necessary. The file shows that the Plan made several attempts to obtain additional information, but none was provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional bedside drainage bags.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed.
You asked the Plan to pre-approve extra heavy-duty hospital bed. You say that you are requesting an appeal for this item. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the enrollee's documented weight is less than 600 pounds.
The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty hospital bed is covered if the beneficiary meets criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. We looked at the file and Medicare rules. The enrollee's weight is less than 600 pounds. Based on this information, we decided that Medicare rules for coverage of extra heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intrathecal/epidural drug infusion pump and inpatient
care for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested procedure is not supported unless there is FDA approval.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation indicates that the trial injection report provided showed a 60% improvement
immediately following procedure, however trial used a medication (Fentanyl) that is not FDA approved for use
in intrathecal pumps. The enrollee does not meet criteria for requested service without psychiatric clearance or
trial with an FDA approved opioid. Additionally, an inpatient stay for implantation of the pump is 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an intrathecal/epidural drug infusion pump and inpatient care 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 (J0897). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to zoledronic acid and there is no indication the enrollee has had an osteoporisis related fracture.
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 Prolia (J0897). Our reviewer says that
the drug is not medically necessary. Our physician reviewer found the patient has not tried and failed the
required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely
be less effective and/or likely have adverse effects for the enrollee. The enrollee does not have a history of
osteoporosis related fracture.
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 (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).