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

We decided that the Plandoes not haveto pre-approveMRI of the right shoulder.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysimaging is not generally indicated for this unless there is a failure of a four-to-six week trial of conservative care.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found you are noted to have right shoulder pain, which appears to have been attributed to a "pinched nerve" and cervical radiculopathy. There is no evidence of shoulder trauma. There is no evidence of shoulder muscle weakness. There is no evidence of conservative therapy having been provided (TC meds, Rx meds, RICE, PT/OT), or of such therapy having been unsuccessful. As such, the requested MRI of the shoulder is not shown to be currently medically necessary or reasonable.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 MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the right shoulder
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implantable cardioverter defibrillator (ICD) placement (33270, 93644).You asked the Plan to pre-approvethe defibrillator placement. You say that the device is medically necessary.The Plan denied your request. The Plan says the defibrillator is not medically necessary. A pacemaker has been approved.The Plan follows Medicare rules. Medicare rules say that an ICD is covered only when 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 defibrillator placement. Our reviewer says that the implantable defibrillator is not medically necessary. Our physician reviewer found based on the records the patient has symptomatic bradycardia. In this circumstance the records document the medical necessity for a pacemaker but not a subcutaneous defibrillator.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 defibrillator placement have not been met.Therefore, we decided that the Plan does not have to pre-approvean implantable cardioverter defibrillator (ICD) placement (33270, 93644).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan drops.
You asked the Plan to pre-approve Rocklatan drops. You say that the eye drops are medically necessary. The
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Rocklatan drops.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires provided on September 27, 2020.
You asked the Plan to pay for lead wires (A4557). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a TENS device was purchased in the previous 12 months therefore the lead wires have been denied.
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 record shows a TENS device was purchased on April 27, 2020, and records supporting the medical necessity of the additional lead wires were not submitted. Based on this information, we decided that Medicare rules for coverage of lead wires (A4557) have not been met. Therefore, we decided that the Plan does not have to pay for lead wires provided on September 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forgauze billed with code A6220 for date of service September 24, 2020.You asked the Plan to pay forthe gauze. The Plan denied your request. The Plan says payment for the supplies in dispute were included in the global surgical package paid for the debridement services performed by the same provider on the same date of service. The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures with the appropriate entry of field 16, includes payment for medical supplies related to the surgery when furnished by the physician who performed the surgery. We looked at the file and Medicare rules. The records show that the surgical procedure represented by CPT code 11043 has the appropriate entry of field 16 and was performed by the same physician who billed for the medical supplies in dispute. The records show that the use of the gauze was related to the debridement procedure. The payment for the gauze is considered to be included in the payment made for the debridement services provided.Therefore, we decided that the Plan does not have to pay forgauze billed with code A6220 for date of service September 24, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveabsolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (CPT Code 78434).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says that the services are considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that PET 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 services. Our physician reviewer found given the unclear nature of the diagnosis of the dilated cardiomyopathy and limitations of standard SPECT study, the PET scan is indicated. The utility of this study is well documented.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 been met.Therefore, we decided that the Plan has to pre-approveabsolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (CPT Code 78434).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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab.You asked the Plan to pre-approvethe Dexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab.. You say that the enrollee needs chemotherapy as soon as possible.The Plan denied your request. The Plan says this drug is not medically reasonable and necessary for the enrollee.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 Dexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab. Our reviewer says that these drugs are not medically reasonable and necessaryfor the enrollee's condition. Our physician reviewer found this medication is not supported by the recognized compendia. This drug requires microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) disease, which is not applicable to this enrollee. Our reviewer found that the requested use of Dexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab is not Food and Drug Administration (FDA) approved for the enrollee's diagnosis. The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer also found that the use of these drugs is not 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 Dexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab. have not been met.Therefore, we decided that the Plan does not have to pre-approveDexamethasone sodium phosphate, Ondansetron, Famotidine, and Nivolumab
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre and sensors (A9276, A9277, A9278) for the enrollee.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says insulin is not used to treat the diabetes.The Plan must follow Medicare rules. The rules say that only therapeutic continuous glucose monitors are covered.The requested items are coded in a way that indicates that the requested monitor is not therapeutic, and therefore, not covered. 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 pre-approvea Freestyle Libre and sensors (A9276, A9277, A9278) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay formolecular pathology testing provided to the enrollee on June 16, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysa panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel.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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered partof the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. The review has determined that the services at issue in this case medically were not 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 the testing have not been met.Therefore, we decided that the Plandoes not haveto pay formolecular pathology testing provided to the enrollee on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D6750, D6240).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere cannot be anymissing posterior teeth in the arch.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. The Plan covers the services when the services are medically necessary and reasonable. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the upper arch is missing teeth #1, 3, 9, 11, 12, 14 and 16. The Plan provisions state for bridgework that "Bridges (excluding third molars) are covered to replace one (1) upper front tooth or two (2) adjacent lower front teeth and there cannot be any missing back teeth." In this instance there are numerous missing back teeth, namely #1, 3, 12, 14 and 16. Given the criteria of the Policy, and the presence of several missing posterior teeth, there is no necessity for the requested procedures.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D6750, D6240)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent testing (87798) provided on May 5, 2020.You asked the Plan to pay forinfectious agent testing. You say that this should be covered.The Plan denied your request. The Plan says the units billed exceeds the MUE.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE valuefor the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 87798 is 13. You billed seventeenunits of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of infectious agent testing have not been met.Therefore, we decided that the Plan does not have to pay forinfectious agent testing (87798) provided on May 5, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the esophagogastroduodenoscopy ( EGD)
biopsy (43239) provided on March 24, 2020.
You asked the Plan to waive the deductible for the esophagogastroduodenoscopy ( EGD) biopsy. You say that
you are appealing the cost share applied to the services because you were in extreme pain due to Covid-19. The
Plan denied your request. The Plan says the claim processed correctly according to the 2020 benefit plan
design. You are responsible for the cost share that was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1,000 deductible for Outpatient surgery.
The item or service you asked the Plan to waive the deductible for, falls within the Outpatient surgery benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000
deductible for Outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time
EGD biopsy was received on March 24, 2020. Therefore, we decided that the Plan does not have to waive the
deductible for the esophagogastroduodenoscopy ( EGD) biopsy (43239) provided on March 24, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea bone marrow transplant.

You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that that they have not been provided with medical documentation that establishes your candidacy for the procedure.

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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. You have a history of hairy cell leukemia that has been treated twice and have pancytopenia likely as aresult of prior treatment. You are not responding to standard treatment for aplastic anemia. An allogenic bone marrow transplant is reasonable and medically necessary. Our physician reviewer found that your condition meets criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approve a bone marrow transplant.

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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve panniculectomy. We decided that the Plan does not have to pre-approve abdominoplasty.

You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan says that this is not medically necessary.

We decided that the Plan has to pre-approve panniculectomy.

The Plan must follow Medicare rules. Medicare rules say that pannulectomy is covered when the panniculus hangs below the level of the pubis, and it causes persistent symptoms despite appropriate medical therapy. 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 for the lower abdominal panniculectomy. Our doctor reviewer found that the enrollee has evidence of a symptomatic lower abdominal pannus that has failed typical dermatologic management, including typical dermatologic compounds used to treat rashes and fungal infections, over a greater than three month period. Photographs show evidence of a pannus that hangs below the level of the pubis. The request for this procedure directly satisfies the Medicare coverage criteria. 

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 panniculectomy have been met. Therefore, we decided that the Plan has to pre-approve panniculectomy.
We also decided that the Plan does not have to pre-approve abdominoplasty.

The Plan must follow Medicare rules. Medicare rules say that abdominoplasty is not covered when performed for repair of diastasis recti. 

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 for abdominoplasty. Our doctor reviewer found that repair of the diastasis rectus (as part of an abdominoplasty) is specifically excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve abdominoplasty.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the impression and custom preparation of lower jawbone prosthesis (21081) provided on August 4, 2020.

You asked the Plan to waive the coinsurance for the impression and custom preparation of lower jawbone prosthesis. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the coinsurance has applied correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance with a purchase cost of $100 or more for durable medical equipment (DME). 

You have been asked to pay a total cost share of $360.96 which is less than the 20% coinsurance for the impression and custom preparation of lower jawbone prosthesis. The service provided falls within the durable medical equipment (DME) benefit category. 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 coinsurance for the impression and custom preparation of lower jawbone prosthesis (21081) provided on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemyocardial perfusion imaging for the enrollee.You asked the Plan to pre-approvethe imaging. You say that this is medically necessary.The Plan denied your request. The Plan says there is no acute myocardial infarction, unstable angina, chronic ischemic heart disease, congenital heart disease, or post-transplant cardiac disease.The Plan must follow Medicare rules. Medicare rules say that radionuclide imaging may be employed in the assessment of a variety of conditions associated with primary coronary artery disease.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 imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the records, the enrollee has some coronary risk but no symptoms or objective findings concerning for coronary ischemia. Therefore, coverage criteria above for nuclear stress testing are not met since there are no documented covered indications for the procedure. Nuclear stress testing has not been shown to be beneficial as a screening test, even in higher risk patients.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 imaging have not been met.Therefore, we decided that the Plan does not have to pre-approvemyocardial perfusion imaging for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown and core buildup, including any pins when required provided on October 1, 2020.You asked the Plan to pay forthe crown and core buildup. The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe crown and core buildup, including any pins when required provided on October 1, 2020.