Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell treatment services provided on March 9, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says knee pain is not a covered condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. The records do not show that the enrollee had an indication for coverage of the services at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the stem cell treatment services provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic - cast high noble metal (D6210) and two pontics - porcelain fused to high noble metal (D6240 x2) provided on January 11, 2021.

You asked the Plan to pay for the pontics. You say that you feel these services should be covered as a crown repair. The Plan denied your request. The Plan says these services are not covered benefits.

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 pontic - cast high noble metal (D6210) and two pontics - porcelain fused to high noble metal (D6240 x2) provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the breast (77049).

You asked the Plan to pre-approve MRI of the breast. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a breast MRI is to be used very selectively and is subject to the criteria listed in the Medicare rules section.

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 MRI of the breast. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 75-year-old female with spontaneous clear left nipple discharge. In this case, the enrollee had a mammography including left diagnostic series followed by left breast ultrasound on December 21, 2020, which revealed scattered fibroglandular elements on mammography and a negative ultrasound. MRI was requested per the radiologist's recommendation for workup. LCD criteria for MRI in the case of unexplained discharge requires ductography to be attempted first before the MRI and this test has not been done.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the breast have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this requested procedure is medically necessary. The Plan denied your request. The Plan says the procedure is considered experimental and 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 the Vertiflex procedure. 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 remains 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
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.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 
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. Our physician reviewer found the patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet joint (64635). You say that you will get much needed pain relief from a radiofrequency ablation. The Plan denied your request. The Plan says the documentation does not support that you have had a response greater than 80% after two medial branch blocks.
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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet joint (64635). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD requires both injections achieve 80% pain relief. This didn't happen and so, the procedure is deemed not medically reasonable or 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet joint (64635) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home visit provided on January 30, 2021 by an out of network (OON) provider.
You asked the Plan to pay for rest home visit. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 rest home visit provided on January 30, 2021 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the interpretation of an upper and lower extremity duplex scan provided on February 26, 2021, billed with two units of 93970-26 as two line items.

You asked the Plan to pay for the duplex scan interpretations as billed. You say that this was correctly billed as there were two separate and distinct services provided. The Plan denied your request. The Plan says that this MUE can only be bypassed if a modifier is used. No modifier was used to indicate both lines can be paid.

The Plan must follow Medicare rules. Medicare rules say that MUEs with an MAI of 3 can be bypassed if there is evidence that the services in excess of the MUE value were actually provided. 

In this case, there is clear evidence that each line was used to report duplex scans of the upper and lower extremities, respectively. The rules do not indicate that a modifier is necessary to allow for payment for both line items. The rule simply states that if there is evidence that the services were actually provided, payment can be made. As such, we find that the coverage rules for payment of the duplex scan interpretations as billed have been met. Therefore, we decided that the Plan has to pay for the interpretation of an upper and lower extremity duplex scan provided on February 26, 2021, billed with two units of 93970-26 as two line items.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve ablation provided on September 30, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had good relief. The Plan denied your request. The Plan says the clinical effectiveness of genicular nerve ablation for knee pain has not been demonstrated.
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 provided. Our physician reviewer found that the enrollee has chronic left knee pain. She is not a surgical candidate. She had diagnostic genicular nerve blocks performed followed by genicular nerves radiofrequency ablation. This procedure is still considered experimental/investigational as there are ongoing clinical trials to determine their role in the treatment of knee osteoarthritis. Therefore, the procedure was medically unreasonable and unnecessary. 
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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve ablation provided on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the Part B step therapy criteria has 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 the injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan,
requires these be trialed first. The documentation does not outline contraindications or reasons these
medications were not considered. Without the support of the documentation, Synvisc-One is not approved, as
step criteria have not been 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Synvisc-One injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for interrogation device evaluation(s) (CPT code 93298 and G2066) provided from May 20, 2020, through November 22, 2020.

You asked the Plan to waive the copayment for the office services. You say that you did not expect to have monthly charges. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received interrogation device evaluation(s) (CPT code 93298 and G2066) from May 20, 2020, through November 22, 2020.

You were asked to pay $45 for date of service May 20, 2020; $45 for date of service May 26, 2020; $45 for date of service June 20, 2020; $45 for date of service July 21, 2020; $45 for date of service August 21, 2020; $35 for date of service September 21, 2020; $35 for date of service October 22, 2020 and $35 for date of service November 22, 2020. Your 2020 EOC states that enrollees must pay a $35 copay for services received from a Level 1 specialist physician and a $45 copay for services received from all other specialists. This means that you have been asked to pay the correct amount based on your contract with the Plan. 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 waive the copayment for interrogation device evaluation(s) (CPT code 93298 and G2066) provided from May 20, 2020, through November 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection (62323).

You asked the Plan to pre-approve an epidural injection. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Of note, the Plan has made several attempts to contact the provider for medical records and no response was received. Therefore, we decided that the Plan does not have to pre-approve an epidural injection (62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).

You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you disagree with the denial because you received dentures in 2013 and 2014. The Plan denied your request. The Plan says these services exceed the benefit allowance.

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, dentures are limited to one set every 5 years. The record shows that you received a complete maxillary denture (D5110) and a mandibular partial denture (D5214) on March 29, 2017 and your dentures benefit has been exhausted.

Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT code E0745) provided to the enrollee on October 6, 2020.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. CPT code E0745 RR KJ KX remains not supported. The submitted medical records indicate the billed item was provided by a health care provider other than the billing health care provider. In addition, the itemized shipping/billing invoice or proof of delivery does not indicate the name of the servicing provider. Therefore, the billed code and modifiers cannot be verified. The submitted invoice indicates the item was shipped on March 30, 2020, and delivered on April 1, 2020; however, the billed date of service is October 6, 2020. Therefore, the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT code E0745) provided to the enrollee on October 6, 2020.
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.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. Our physician reviewer found the patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic stimulation therapy for treatment of diabetic neuropathy.

You asked the Plan to pre-approve therapeutic stimulation therapy for treatment of diabetic neuropathy. You say that this procedure is medically necessary to manage your pain. The Plan denied your request. The Plan says this procedure is considered experimental/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 therapeutic stimulation therapy for treatment of diabetic neuropathy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational therapy and as such is deemed not medically reasonable or 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 therapeutic stimulation therapy for treatment of diabetic neuropathy have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic stimulation therapy for treatment of diabetic neuropathy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira Pen.

You asked the Plan to pre-approve Humira Pen. You say that the enrollee has psoriasis and is having no side effects on this drug. The Plan denied your request. The Plan says the requested drug is not a covered 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 Humira Pen.