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

We decided that the Plan does not have to reimburse you for the wig purchased from provider on February 14, 2019.You asked the Plan to reimburse you for the wig. You say that the Plan should reimburse you.The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say that a cranial prosthesis is statutorily excluded. 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 reimburse you for the wig purchased from provider on February 14, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora hand x-ray (CPT 73130) provided to the enrollee on September 13, 2019.You asked the Plan to pay forthe x-ray. You say that this should be paid for.The Plan denied your request. The Plan says that the diagnosis code associated to this CPT code are mismatched to the procedure modifier on the claim line.The Plan must follow Medicare rules. The rules say thatMedicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.Additionally, 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 73130 is "Radiologic examination, hand."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 x-ray. Our reviewers says that the services at issue in this case were supported by the records. Our physician reviewer found the enrollee apparently suffered trauma to his left hand/4th digit, for which an x-ray of the left hand was performed. The indication on the x-ray supports the medical necessity of the x-ray. The health plan has failed to show that the diagnosis is inaccurate or that the x-ray was not medically necessary.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-ray have been met.Therefore, we decided that the Plan has to pay fora hand x-ray (CPT 73130) provided to the enrollee on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the silicone breast prosthesis (L8030)You asked the Plan to pre-approvethe silicone breast prosthesis. You say that you work outside and in your yard. You do physical work and the gel breaks down. It does not matter what you do the gel breaks down. There is no way for it to last for two years.The Plan denied your request. The Plan says replacement for silicone breast prostheses is limited to one every 2 years for each side.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The records show that a silicone breast prostheses was obtained on November 19, 2019 and you will not be eligible for replacement until November 2021. Based on this information, we decided that Medicare rules for coverage of the silicone breast prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approvethe silicone breast prosthesis (L8030)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on November 22, 2019.
You asked the Plan to pay for foot orthotics. You say that you need orthopedic shoes because you had an ankle injury affecting your gait. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The Plan denied your request. The Plan says the requested Opdivo 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 Opdivo. Our reviewer says that the requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is with metastatic squamous cell lung cancer, a type of non-small cell lung cancer (NSCLC) who has been treated with several chemotherapy regimens including Keytruda. He had progression of the cancer on Keytruda in July, 2019. Opdivo is FDA approved for the requested use. Per the FDA website, Opdivo is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) with progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Opdivo. The enrollee's cancer is negative for EGFR and ALK mutations. The use of Opdivo in this clinical situation is not supported by the NCCN compendium. The NCCN compendium states the drug is recommended if there has been no prior progression on a PD-1/PDL-1 inhibitor. Keytruda is a PD-1 inhibitor. The enrollee's cancer progressed on Keytruda. Therefore the requested use is not recommended and the documentation does not support that Opdivo is safe and effective and otherwise medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH, having initially been admitted with a perforated marginal ulcer. The enrollee subsequently developed respiratory and renal failure. The enrollee was intubated/ventilated and started on hemodialysis. The enrollee has since received a tracheotomy and has tolerated weaning to daytime tracheotomy collar. Given her morbid obesity, it is unclear if full ventilator liberation and decannulation are expected or advisable. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 3, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 27, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on April 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the initial periapical x-ray (D0220) and an additional periapical x-ray (D0230) provided on December 17, 2019.You asked the Plan to pay for the dental services. You say that you only had preventive work done. You say that you have the same services done every year for the past 20 years.The Plan denied your request. The Plan says the benefit for an oral exam and prophylaxis have been exhausted. The Plan also says periapical x-rays are not covered services under your 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 and oral exams and prophylaxis are covered services, the benefit of once per year have been exhausted. The record shows that the Plan paid for the oral exam and prophylaxis that you received on June 6, 2019. Additionally, periapical x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the initial periapical x-ray (D0220) and an additional periapical x-ray (D0230) provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not show that you required emergent or urgently needed care, that you require kidney dialysis services outside of the Plan's service area, that you required services that Plan providers cannot provide or that you were referred by an in-network provider.
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 has network providers available who can provide 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 medical services provided on November 8, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204 and 36415) provided on September 15, 2017 by an out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this service was medically necessary and the enrollee presented only their Medicare card. The Plan denied your request. The Plan says these services were not authorized.
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 has network providers available who can provide 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 (99204 and 36415) provided on September 15, 2017 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth provided on November 29, 2019.
You asked the Plan to pay for the removal of an impacted tooth. You say that this procedure was a necessity. You also say that you contacted a number of dentists and were told none of them accepted your insurance. The Plan denied your request. The Plan says the service is not covered under your plan.
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 the removal of an impacted tooth provided on November 29, 2019.
Your complaint about being dissatisfied with the Plan's help is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the foot inserts to help with your pain. You say that since the inserts are necessary, you would like the Plan to consider paying for them. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the combination of Opdivo and Yervoy.
You asked the Plan to pre-approve the combination of Opdivo and Yervoy. You say that the requested combination of Opdivo and Yervoy is medically necessary. The Plan denied your request. The Plan says the requested combination of Opdivo and Yervoy 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 the combination of Opdivo and Yervoy. Our reviewer says that the requested combination of Opdivo and Yervoy is not medically necessary. Our physician reviewer found the enrollee is with progressive metastatic pancreatic cancer and has high tumor mutational burden. The requested combination of Opdivo and Yervoy is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of the requested combination is listed as not indicated, not supported or not recommended in any of the compendia. 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 combination of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve the combination of Opdivo and Yervoy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Grafix wound dressings (A4133).You asked the Plan to pre-approve the skin substitute. You say that this service is medically necessary. The Plan denied your request. The Plan says the records indicate that the wound is not clean.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 skin substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in order for a wound dressing/skin substitute to be authorized, the wound must be free of underlying cellulitis, osteomyelitis, foreign body, or malignant process. For venous stasis ulcers, compression therapy must be provided with documented diligent use of a multilayer dressing, compression stocking of greater than 20 mmHg pressure or pneumatic compression must be present and the member must have control of the edema venous hypertension or lymphedema. In the most recent progress note the member is noted to have a superficial infection of the ulcerations necessitating topical antibiotic ointment. Furthermore, the member is noted to have compromised vascular status as the progress note advises that the posterior tibial pulse is nonpalpable left side. Finally, the member is noted to have continued edema to the left lower extremity. 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 skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve Grafix wound dressings (A4133).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Guardian CGM and supplies.
You asked the Plan to pre-approve a non-therapeutic CGM. You say that your current CGM is inaccurate and doesn't have an alarm for an upcoming low. The Plan denied your request. The Plan says the Guardian CGM is not considered to be a therapeutic device per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The only CGM devices covered by Medicare are the Dexcom G6 and FreeStyle Libre. Based on this information, we decided that Medicare rules for coverage of the Guardian CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Guardian CGM and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a lateral retinacular release (27425) provided on May 28, 2019. You asked the Plan to pay for a lateral retinacular release. You say that this should be reprocessed. The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure. The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27425. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for a lateral retinacular release have not been met. Therefore, we decided that the Plan does not have to pay for a lateral retinacular release (27425) provided on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (99354) provided on May 7, 2019.You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed service.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 99354 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denyingthe request to pay for the psychotherapy services. Our reviewer says that CPT code 99534 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include the necessary information to validate that this service was provided. There is no documentation of the additional time spend above and beyond the evaluation and management service performed during the same encounter. 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 psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (99354) provided on May 7, 2019.