Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips and lancets. You asked the Plan to pre-approve the supplies. You say that you have diabetes and you are not currently being treated with the requested product. The Plan denied your request. The Plan says the enrollee has not failed the preferred diabetic testing supplies. 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 supplies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documented medical necessary for the requested specific brands over the preferred brands. 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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve test strips and lancets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RUXIENCE. You asked the Plan to pre-approve RUXIENCE. You say that the requested RUXIENCE is medically necessary. The Plan denied your request. The Plan says the requested RUXIENCE 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 RUXIENCE. Our reviewer says that the requested RUXIENCE is not medically necessary. Our physician reviewer found the enrollee is diagnosed with immune thrombocytopenic purpura. The requested use of RUXIENCE is not FDA approved for the enrollee's diagnosis. The use of RUXIENCE is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. RUXIENCE is used for refractory ITP. Given the enrollee's platelets are 81-90 this would not be considered refractory. He has no indication why he would need to have platelets higher as in a safe 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 RUXIENCE have not been met. Therefore, we decided that the Plan does not have to pre-approve RUXIENCE.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve home health care. You say that other home health care agencies do not cover the area where the enrollee resides, and the enrollee has not progressed to a functional level to receive services outside the home. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network home health care agency.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for podiatry services provided on January 9, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you received routine foot care and should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
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 provide any documentation, such as medical records, clearly showing their reason for denying your request. Therefore, we decided that the Plan has to waive the copayment for podiatry services provided on January 9, 2020.
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 pre-approve a crown (D2751) for tooth #19. You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the x-rays do not show that tooth #19 is badly broken or rotten. 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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the policy criteria states that crowns are to be considered where there are two or more cusps damaged and four or more surfaces involved. In this circumstance there is an obvious fracture of one cusp on a molar that has a small occlusal amalgam restoration. Our reviewer found that under the Plan criteria the tooth in question, #19, would not qualify for a crown restoration, and would be restorable by way of a conventional composite or even amalgam restoration. Our physician reviewer also found that due to the lack of substantial structural loss as defined under the Plan, there is no necessity for a crown on tooth #19. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.You asked the Plan to pre-approve auricular peripheral nerve stimulator. You say that this request is not for acupuncture and this device is medically necessary for the enrollee.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this device is considered an acupuncture service which is not covered by Medicare.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 auricular peripheral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of this device is not supported by evidence-based peer reviewed literature. This device is considered experimental/investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of auricular peripheral nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS HF system.You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary.The Plan denied your request. The Plan says the requested CardioMEMS HF system is not medically necessary.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 CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the enrollee is with a history of diabetes, sleep apnea, deep venous thrombosis, pulmonary embolism, coronary artery disease, defibrillator placement and NYSHA Class III congestive heart failure with reduced LV ejection fraction (LVEF 25-30%) requiring hospitalization.In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results.Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 CardioMEMS HF system have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says a CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 CT scan. Our reviewer says that the requested CT scan of the chest is not medically reasonable and necessary. Our physician reviewer found that there is no specific clinical rationale for the requested chest CT scan. There is no provided recent clinical evaluation and no documentation to suspect complication from the lung infection, new abnormalities on chest x-ray, or lack of clinical response to treatment. The enrollee was described in February 2020 as "feeling okay," with mild dyspnea on exertion, but not at rest. There was no recent history of excessive cough or sputum production. Per the guidelines, coverage for a CT scan for the evaluation of pneumonia requires completion of a recent chest x-ray prior to considering CT imaging of the chest. The chest x-ray should be performed within the last 60 days and the results must be abnormal. The clinical information provided does not meet these criteria. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not insulin treated. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are covered by Medicare when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The record shows that the enrollee is not currently treated with insulin. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a four wheeled walker with seat.You asked the Plan to pre-approve a four wheeled walker with seat (E0143, E0156).You say that because of your medical condition you need a walker with a seat.The Plan denied your request. The Plan says you received a walker one year ago and the documentation provided does not show a change in your condition. 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 four wheeled walker with seat (E0143, E0156).Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the requirement for a four wheeled walker with seat (E0143, E0156). The documentation does not reveal a physical examination revealing that the enrollee has a mobility limitation that significantly impairs the ability to participate in one or more mobility-related activities of daily living (MRADL) in the home. The documentation indicates the enrollee received a walker in May 2019 and there is no evidence that the enrollee is unable to resolve the functional mobility deficit with use of the current walker.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 four wheeled walker with seat (E0143, E0156). have not been met.Therefore, we decided that the Plan does not have to pre-approve a four wheeled walker with seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (CPT E0218).
You asked the Plan to pre-approve the fluid circulating cold pad with pump. You say that your arm is in a sleeve and the cold therapy machine allows you to move. You say that, without it, your recovery will be difficult. You say that your surgeon strongly request that you have the device in order to complete your recovery from shoulder rotator duff surgery. The Plan denied your request. The Plan says the item in dispute is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The rules state that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (CPT E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary for the enrollee.The Plan denied your request. The Plan says information submitted fails to meet medical necessity criteria.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator. Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found the enrollee has COPD. The enrollee has not yet been tested for obstructive sleep apnea, but that seems a likely diagnosis. Neither CPAP nor BiPAP have been tried.  Medicare does not cover a home ventilator when used as a BiPAP device.  The home ventilator is not medically necessary, and the denial is upheld.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 home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for trifocal lenses (V2300) miscellaneous vision services (V2799) provided February 18, 2020 by an out of network provider. You asked the Plan to pay for the vision services. You say that none of the healthcare literature indicates that you had to search for an optical provider that was affiliated with the Plan and you feel that you should be reimbursed for the prescription lenses. The Plan denied your request. The Plan says services provided by an out of network provider is not covered by the plan. 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. The Plan covers these services when provided by an in-network provider. You can find this information on page 3-4 of the plan's 2020 Evidence of Coverage. We looked at the file and the Plan's rules. Services provided by an out of network provider is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for trifocal lenses (V2300) miscellaneous vision services (V2799) provided February 18, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 10, 2020.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the room through the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe provisional splinting provided on January 15, 2020.You asked the Plan to pay forthe provisional splinting. You say that your dentist wanted to save the tooth by bonding it to the teeth on either side of it.The Plan denied your request. The Plansays your plan does not cover this procedure.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 forthe provisional splinting provided on January 15, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-care/home management training, each 15 minutes
(97535) provided February 24, 2020 to February 28, 2020.
You asked the Plan to pay for the self-care/home management training. You say that you are appealing the
denial of the services. The Plan denied your request. The Plan says this service was billed incorrectly. This
billed procedure is mutually exclusive to therapeutic activities another procedure which was billed on the same
date of service by the same provider under same claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Per NCCI PTP Coding Edits code 97535 is a column 2 component of column 1 code 97530. A modifier is
allowed to unbundle these codes. The documentation should clearly show that these procedures were distinct
and independent to one another. Supporting documentation indicating that these services were performed
distinctly was not included in the submitted documentation. Based on this information, we decided that
Medicare rules for coverage of the self-care/home management training have not been met. Therefore, we
decided that the Plan does not have to pay for the self-care/home management training, each 15 minutes
(97535) provided February 24, 2020 to February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTecentriq for the enrollee.You asked the Plan to pre-approveTecentriq.You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this drug is not supported for the enrollee's condition.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 Tecentriq. Our reviewer says that Tecentriq is not medically reasonable and necessary for the enrollee in this case. The requested use of Tecentriq is not FDA approved. The requested use is not supported in any of the CMS approved compendia.We could not find any supporting citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Tecentriq.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met.Therefore, we decided that the Plan does not have to pre-approveTecentriq for the enrollee.