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

We decided that the Plan does not have to pre-approve Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542).

You asked the Plan to pre-approve Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542). You say that you want the enrollee to have this test. The Plan denied your request. The Plan says the enrollee has not met criteria for the Decipher assay.

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 Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542). Our reviewer says that the Decipher test is not reasonable and medically necessary. The records do not indicate the clinical stage or whether the patient has had a radical prostatectomy. Our physician reviewer found Decipher (81542) assay is covered for Medicare members only when all the following criteria are met: Patient with prostate cancer who has undergone a RP (radical prostatectomy) within the previous 60 months and is being considered for postoperative secondary therapy due to one or more cancer recurrence risk factors, and patient must have achieved initial PSA nadir (defined as undetectable PSA) within 120 days of RP surgery, and patient must not have any evidence of distant metastasis, and patient must not have received any neoadjuvant treatment prior to surgery, and Decipher GC is performed on a patient's RP specimen, and patient's surgical pathology report or medical records must have documented presence of adverse pathology: Pathological stage T2 disease with a positive surgical margin, or Pathological stage T3 disease (e.g., extraprostatic extension, seminal vesicle invasion, bladder neck invasion), or Rising PSA after initial PSA nadir, and Testing has been ordered by a physician who is certified in the GenomeDX Decipher Certification and Training Registry (CTR). These criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542) have not been met. Therefore, we decided that the Plan does not have to pre-approve Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score (81542).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).

You asked the Plan to pre-approve the maxillary partial denture. You say that you need this service to be approved for coverage. The Plan denied your request. The Plan says this service is allowed 1 time in a 60 month period. The Plan also says that you have already received this service within that time frame.

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, maxillary partial denture (D5213) is limited to one of either code D5211, D5213, D5225, or D5281 once per 60 months. The record shows that you received a maxillary partial denture (D5213) on April 30, 2019 and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99201) provided December 8, 2020.

You asked the Plan to pay for the office visit. You say that you are appealing the denial and is concerned that if your insurance will not pay for services, the doctors will not be able to see you again. The Plan denied your request. The Plan says office visits performed by a chiropractor are non-covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99201) provided December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you were approved for a pneumatic compressor and needs the wraps to improve leg swelling which keeps her from being able to walk. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the compression stockings identified with code A6549.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested service.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that According to the records the enrollee does not qualify for a screening CT based having no smoking history and her age. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you need a CGM to better monitor your blood sugar levels. The Plan denied your request. The Plan says the clinical information submitted indicates that you are not on insulin.

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 you do not use insulin with at least three daily injections nor 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 a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received December 18, 2020 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that the plan should pay 100% of the cost billed by the provider. The Plan denied your request. The Plan says providers are paid based on a Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider.

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 payment is in excess of those covered under this benefit. The Plan has agreed to pay 100% of the MAC ($22 for D0210, and $47 for D1110). The Plan contract states that you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received December 18, 2020 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260) for the upper left and upper right quadrant.

You asked the Plan to pre-approve the dental services. You say that you have been trying for years to get this service covered. You also say that you do not want to lose all of your teeth. The Plan denied your request. The Plan says osseous surgery is not listed as a covered service. The Plan also says that these services are not covered by Medicare.

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 osseous surgery is not among those covered under this benefit. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4260) for the upper left and upper right quadrant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara (J3358).

You asked the Plan to pre-approve Stelara. You say that Stelara is medically necessary. The Plan denied your request. The Plan says a trial of Infliximab or equivalent is required before alternatives can be considered.

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 Stelara. Our reviewer says that Stelara is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason it would be ineffective or unsafe for the 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 Stelara have not been met. Therefore, we decided that the Plan does not have to pre-approve Stelara (J3358).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), non-proportional controller (E2321), contoured arm support, and shoe holder.

You asked the Plan to pre-approve an expandable controller, non-proportional controller, contoured arm support, and shoe holder. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that certain power wheelchair accessories are 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 an expandable controller, non-proportional controller, contoured arm support, and shoe holder. Our reviewer says that the items are not medically necessary. Our physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness is not medically necessary. The documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the upper extremities with the ability to feed yourself indicates that you can control any power options through their own individual switches. The non-proportional controller (E2321) exceeds your medical need and is not medically necessary as your strength and function should be sufficient to control the wheelchair with the controller included in the wheelchair base. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, non-proportional controller, contoured arm support, and shoe holder have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), non-proportional controller (E2321), contoured arm support, and shoe holder.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short-term acute care hospitals. The enrollee is
receiving acute hospital care, and acute care services have not been denied. The documentation does not
support that the enrollee in this case requires services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. The clinical assessment in the case file does not support that the
enrollee is reasonably expected to benefit from, and improve with, LTACH services that are not available in the
current acute care hospital. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis 0.05%.

You asked the Plan to pre-approve Restasis. You say that Restasis is medically necessary. The Plan denied your request. The Plan says Restasis is not eligible for coverage under the Part B medical benefit.

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 Restasis 0.05%.

Benefits for Restasis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 21, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says
authorization is required for these 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 requested provider in this case is not a network provider with the Plan. 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 a domiciliary, rest home visit provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 21,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says assays of vitamin testing are not covered since all clinically relevant vitamins have specific
assays.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there was no specific clinical rationale for obtained studies.
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 pay for laboratory services provided to the enrollee on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an after-hours office visit (D9440), bone replacement graft (D7953) and surgical placement of an endosteal implant body (D6010) provided on October 24, 2020 and November 11, 2020.
You asked the Plan to pay for the dental services. You say that these services were medically necessary and urgent. The Plan denied your request. The Plan says these services are 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 an after-hours office visit (D9440), bone replacement graft (D7953) and surgical placement of an endosteal implant body (D6010) provided on October 24, 2020 and November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 31, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider 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 office visit provided on December 31, 2020 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case the enrollee has known chronic obstructive pulmonary disease and emphysema. A chest x ray and pulmonary function tests have been ordered. The provided medical records do not support the medical necessity or reasonableness of the requested test as defined by Medicare rules. The elements of the coverage rules are not satisfied. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the thorax.