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

We decided that the Plan does not have to pay for the electrocardiogram (EKG) with tracing (93005) and the
hospital outpatient clinic visit (G0463) provided on July 9, 2020.
You asked the Plan to pay for the physician services. You say that per the PPS Exempt Cancer Institute, the
provider is exempt from the Medicare DRG payment methodology. You also say that payment should be made
at the rates established and updated by CMS on a periodic basis. The Plan denied your request. The Plan says
the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan
also says it is the provider's responsibility to verify the member's coverage before rendering services and to
know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 8, 2020. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the electrocardiogram
(EKG) with tracing (93005) and the hospital outpatient clinic visit (G0463) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure, or pay more for the first intraoral periapical x-ray, resin-based composite, and crown provided on December 8, 2020 by an OON provider.

You asked the Plan to pay for the preventive procedure, and to pay more for the first intraoral periapical x-ray, resin-based composite, and crown. You say that you believe the Plan has not paid everything for the dental services that they should have paid. The Plan denied your request. The Plan says the preventive procedure is not a covered service. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, unspecified preventive procedure is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure, or pay more for the first intraoral periapical x-ray, resin-based composite, and crown provided on December 8, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 7, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says to report a comprehensive genomic profile, service providers should use CPT code 81479.
The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report Guardant360 testing. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, Guardant360 testing must be billed with one unit of CPT code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove continuous glucose monitoring system (CGM).

You asked the Plan to preapprove the CGM. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.

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 and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to preapprove continuous glucose monitoring system (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex has not been shown to be safe and effective compared to the gold standard of decompression.
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 Vertiflex. 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 its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life2000 ventilation system.

You asked the Plan to pre-approve the Life2000 ventilation system. You say that this item is medically necessary.The Plan denied your request. The Plan says this item is not medically reasonable and necessary.

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 the Life2000 ventilation system. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found this system is not a true ventilator, and there is insufficient evidence that it is effective in the treatment of COPD. This patient does have COPD, but there is no documentation of CO2 retention.

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 Life2000 ventilation system have not been met.Therefore, we decided that the Plan does not have to pre-approve the Life2000 ventilation system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda injections (J9271).
You asked the Plan to pre-approve the Keytruda injections. The Plan denied your request. The Plan says there is no documentation submitted supporting positive efficacy and safety, to support the off-label requested use of Keytruda for the requested diagnosis after previous documented disease progression from use of Opdivo (Nivolumab) and Yervoy (Ipilimumab).
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 the Keytruda injections. Our reviewer says that Keytruda injections (J9271) are not medically reasonable and necessary for the enrollee. Our physician reviewer found per the compendia, as the enrollee has failed Opdivo/Yervoy another checkpoint inhibitor, Keytruda, cannot be approved. Our reviewer also found that Keytruda is FDA approved and compendia based for metastatic melanoma, but not after progression on another programmed death ligand 1 (PD-L1) inhibitor. 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 Keytruda injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda injections (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Valacyclovir tablets.
You asked the Plan to pre-approve Valacyclovir tablets. You say that the enrollee is immunocompromised due to bone marrow transplantation. The Plan denied your request. The Plan says the requested drug is intended for enrollee self-administration. The Plan also says that this drug is not covered for the enrollee's condition by Medicare Part B.
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 Valacyclovir tablets.
Benefits for Valacyclovir tablets 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 pay for the hydrotherapy walk-in tub provided September 24, 2020.

You asked the Plan to pay for the hydrotherapy walk-in tub. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered by Medicare because hygienic equipment is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the hydrotherapy walk-in tub provided September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an amniotic tissue injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that the enrollee has increasing low back pain.The Plan denied your request. The Plan says there is insufficient evidence to support this request.

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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the amniotic fluid injection for back pain does is not sufficiently supported in the literature. Therefore,its use remains experimental and investigational for this indication.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve an amniotic tissue injection for the enrollee.
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. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says the FDA has not approved Keytruda for the treatment of the member's condition at the requested dosage and regimen.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 reviewer says that single agent Keytruda is not indicated per the major compendia and literature. Our physician reviewer found single agent Keytruda is not approvable unless the tumor is deficient in protein.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial tooth removal (coronectomy) (D7251) provided on
December 1, 2020.
You asked the Plan to pay for the partial tooth removal. You say that this was a medically necessary oral
surgery procedure that should be covered. The Plan denied your request. The Plan says this procedure is not
covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial
tooth removal (coronectomy) (D7251) provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 4, 2020.
You asked the Plan to pay for the eye refraction. You say that this charge had been waived in the past and you
do not agree with this bill. The Plan denied your request. The Plan says eye refractions are not covered by
Medicare and are only covered by the Plan's supplemental vision benefit when they are performed as part of a
routine vision exam by the Plan's specified vision care provider. The refraction performed is not considered
routine as it was provided in relation to a pre-existing medical condition.
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 they are provided as part of a routine eye exam received from a
Plan-participating vision care provider.
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 eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for
the eye refraction (92015) provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve image-guided radiation therapy (rotational arc therapy IGRT).
You asked the Plan to pre-approve IGRT. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the records do not show a recent consultation with the doctor describing a need for the requested treatment, the number and type of treatments needed, the results of other testing related to the requested treatment, and the stage of the enrollee's cancer.
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 IGRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the American Society for Radiation Oncology (ASTRO) model policy on intensity-modulated radiation therapy (IMRT) described IGRT in general terms: Image Guided Radiation Therapy (IGRT) utilizes imaging technology to modify treatment delivery to account for changes in the position of the intended target. IGRT is indicated for use in patients whose tumors are located near or within critical structures and/or in tissue with inherent setup variation. In general, the technical components of IGRT are bundled with IMRT as it is assumed that with IMRT that IGRT is being used. So only the professional component of IGRT is billed. As IMRT was approved for this patient (and not disputed in this patient undergoing prior brain fractionated radiosurgery and now being offered whole brain radiation with IMRT/volumetric modulated arc therapy (VMAT)), it would be within accepted standards of medical practice to use IGRT with IMRT delivery due to the more conformal radiation delivery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have been met. Therefore, we decided that the Plan has to pre-approve image-guided radiation therapy (rotational arc therapy IGRT).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission.
You asked the Plan to pre-approve inpatient psychiatric admission. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of April 22, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health occupational therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON home health services. You say that you would like to use the OON provider as they already work with other residents, and you feel they do a good job. The Plan denied your request. The Plan says there are several other home health agencies in your network able to provide the services you require. There is no medical reason to allow for OON care.
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 home health occupational therapy to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit and brief emotional/behavioral assessment provided on November 4, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit and brief emotional/behavioral assessment. You say that your physician renders medical care for the patients in the facility as requested by the facility. The Plan denied your request. The Plan says the services were rendered by a non-participating provider, and the rendering facility is also OON. The Plan also says that prior authorization was not 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 had network providers available who could have provided 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 the domiciliary or rest home visit and brief emotional/behavioral assessment provided on November 4, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 15, 2020.