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

We decided that the Plan does not have to pay for arthrodesis (28730 and 28730) and hallux valgus correction (28290) provided on January 15, 2020.

You asked the Plan to pay for the arthrodesis and hallux valgus correction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 28730 is arthrodesis, midtarsal or tarsometatarsal, multiple or transverse. 

The CPT Code Manual definition of code 28290 is correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method. 

We asked our coder 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 arthrodesis and hallux valgus correction. Our reviewer says that CPT codes 28730, 28290 and 28730 do not meet criteria for billing or reimbursement consideration. The operative report did not clearly verify fusion was performed on midtarsal or tarsometatarsal. Our reviewer found CPT 28270 would be inclusive to CPT 29285 and would not be reported separately.

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 arthrodesis and hallux valgus correction have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis (28730 and 28730) and hallux valgus correction (28290) provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 2.

You asked the Plan to pre-approve the dental service. You say that tooth # 2 needs a crown. The Plan denied your request. The Plan says core build up is not listed as a covered service.

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 core build up (D2950) for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this service is necessary for your medical condition. The Plan denied your request. The Plan says you do not meet prior authorization criteria for the therapeutic continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the respiratory disorder panel provided on May 22, 2020.

You asked the Plan to pay for the respiratory disorder panel. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says that molecular genetic screening testing
is not a Medicare benefit for the diagnoses as listed on the claim.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.

This testing was ordered by a contract provider. The file does not show that the plan provided notice that the
respiratory disorder panel would not be covered. Under Medicare rules, this means the respiratory disorder
panel is considered approved by the plan. Additionally, this testing is not considered screening as it is directly
related to the member's symptoms and condition. Therefore, we decided that the Plan has to pay for the
respiratory disorder panel provided on May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery.

You asked the Plan to pre-approve the Vertiflex surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the Vertiflex surgery 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 the Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex spacer device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 96 additional routine transportation trips.

You asked the Plan to pre-approve 96 additional routine transportation trips. You say that you need additional trips to get to your dialysis appointments. The Plan denied your request. The Plan says you have only 37 of your 60 trips remaining.

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 60 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 96 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tricuspid valve replacement using an Edward Sapien 3 transcatheter valve replacement system.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the device is not FDA approved, it is considered experimental and/or investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have both severe tricuspid and mitral valve disease with significant elevation of both left and right sided pressures as well as both left and right sided heart failure symptoms on very low dose torsemide medication. In this circumstance, tricuspid valve in valve placement would not be expected to improve left sided heart failure and the documentation does not support that you cannot tolerate or is refractory to higher dose diuretic medication to treat elevated filling pressures, ascites and heart failure symptoms. Also, edema is reported to be only very mild. Overall the documentation does not support the medical necessity for tricuspid valve in valve replacement at this time. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve tricuspid valve replacement using an Edward Sapien 3 transcatheter valve replacement system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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 covered.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The file shows that the enrollee is not insulin-treated. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you respectfully disagree with this determination and ask for review of the enclosed documentation supporting medical necessity of the requested equipment. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve provisional crowns (D2799 x 5).

You asked the Plan to pre-approve the provisional crowns. You say that you need these services. You also say that you cannot chew. The Plan denied your request. The Plan says provisional crowns are not listed as covered services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, 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 provisional crowns (D2799 x 5).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the triamcinolone acetonide injection (j3301) provided on August 11, 2020.

You asked the Plan to pay for the triamcinolone acetonide injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg. 

We asked our coder 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 triamcinolone acetonide injection. Our reviewer says that CPT code J3301 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation of an injection, triamcinolone acetonide, not otherwise specified, 10 mg being provided on August 11, 2020, 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 triamcinolone acetonide injection have not been met. Therefore, we decided that the Plan does not have to pay for the triamcinolone acetonide injection (j3301) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an erupted tooth with sedation and oral drugs.

You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these services are 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 or services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Removal of an erupted tooth is not considered a simple extraction and therefore is not covered. Sedation and oral drugs are also not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of an erupted tooth with sedation and oral drugs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a wheelchair.

You asked the Plan to pre-approve power seat elevation feature. You say that you need this feature due to your
condition. The Plan denied your request. The Plan says the denial of authorization for this feature is correct,
because a power seat elevation feature is not covered by Medicare.

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.

We looked at the file and Medicare rules. A power seat elevation feature is not covered by Medicare.
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a
wheelchair.
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 inpatient rehab is the only chance the member has to
returning to her prior level of function. The Plan denied your request. The Plan says that the enrollee can safely
receive the services needed in other settings.

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. 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 right leg weakness
and a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient
admission. 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 documents a need for physical and occupational therapy, it does not
document a need for an intensive rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription eyewear and over-the-counter items provided
from June 26, 2020, through October 20, 2020.

You asked the Plan to pay for the prescription eyewear and over-the-counter items. You say that you would
like reconsideration because you were under the impression that you had the Flex Benefit under your plan. The
Plan denied your request. The Plan says you were ineligible for reimbursement under the Flex Benefit in 2020.

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. Based on this information, we decided that the Plan's rules for
coverage of the prescription eyewear and over-the-counter items have not been met. Specifically, there is no
record that you made payment for the eyeglasses and that reimbursement is due. Additionally, the record
indicates that you were not eligible for the Flex Benefit to cover the over-the-counter items in 2020. Therefore,
we decided that the Plan does not have to pay for prescription eyewear and over-the-counter items provided
from June 26, 2020, through October 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the use of the drug is not being prescribed for a medically-accepted indication.

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 Keytruda. Our physician reviewer found that the enrollee has a diagnosis of adenocarcinoma, primary site undetermined. There is no documentation that Keytruda is FDA-approved for the enrollee's diagnosis. The records do not document that the enrollee has a mismatch repair deficient (dMMR)/microsatellite instability-high tumor, or tumor mutational burden-high tumor. The requested use of Keytruda is not listed as not indicated, not supported or not recommended in any of the compendia. There is no support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245, 96372).

You asked the Plan to pre-approve Ilumya. You say that this is the best treatment for the enrollee. 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 Ilumya. Our reviewer says that the criteria for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial of Humira, Enbrel or Skyrizi before they will approve the requested drug. The documentation does not support that the enrollee has tried Humira, Enbrel or Skyrizi or that these drugs would likely be less effective or 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245, 96372).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable neurostimulator (L8679).

You asked the Plan to pre-approve an implantable neurostimulator. You say that the enrollee has failed
conservative care and medication. 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 a spinal cord stimulator trial can be covered only for
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to
implantation. Such screening must include a psychological evaluation.

The file does not show that a psychological evaluation has been conducted in conjunction with this request for
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve an implantable
neurostimulator (L8679).