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

We decided that the Plan does not have to pre-approve Fluorouracil and methotrexate (with Meperidine, Promethazine and Palonosetron).

You asked the Plan to pre-approve Fluorouracil and methotrexate. You say that the enrollee has had prior therapies of Keytruda with adverse effects. The Plan denied your request. The Plan says the off label use of the requested drugs is not medically accepted per Medicare rules.

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 Fluorouracil and methotrexate. Our reviewer says that the requested drugs are not medically necessary. Our physician reviewer found the requested use of Fluorouracil and methotrexate (with Meperidine, Promethazine and Palonosetron) is not FDA-approved for the enrollee's diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The reviewer found that the requested use is not listed as not indicated, not supported or not recommended in any of the compendia either. Therefore, the reviewer found that the requested drugs are 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 Fluorouracil and methotrexate have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluorouracil and methotrexate (with Meperidine, Promethazine and Palonosetron).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported with radiologic evidence.

The Plan must follow Medicare rules. Medicare rules say that that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee. 

We looked at the file and Medicare rules. The submitted medical records do not included radiologic evidence of the enrollee's diagnosis. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final
restoration) on teeth #9 (CPT code D3310) and crown - porcelain fused to high noble metal on teeth #9 and 10
(D2750).

You asked the Plan to pre-approve the dental services. You say that this is not a cosmetic procedure. The Plan
denied your request. The Plan says you exhausted your 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. Review of the file show that you were approved for crown - porcelain
fused to high noble metal on tooth #11 and endodontic therapy, anterior tooth (excluding final restoration) on
tooth #11. Therefore, you exhausted your benefit for the services. The health plan contract says Root Canal -
up to one (1) per calendar year. Benefit limited to codes: D3310 / D3320 / D3330. Crown - up to 1 per
calendar year. Benefit limited to codes: D2740 / D2750. Therefore, we decided that the Plan does not have to
pre-approve endodontic therapy, anterior tooth (excluding final restoration) on teeth #9 (CPT code D3310) and
crown - porcelain fused to high noble metal on teeth #9 and 10 (D2750).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (CPT
code(s): 22869, 22870 and C1821) for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are 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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex Superion device placement surgery (CPT code(s): 22869, 22870 and C1821) for
the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110) and the 
mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the maxillary and partial mandibular dentures. You say that you were told 
this would be covered. The Plan denied your request. The Plan says this is not covered under your Plan 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 pre-approve the 
complete denture - maxillary (D5110) and the mandibular partial denture (D5212).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 6, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and 
intraoral periapical radiographic images (D0230) provided November 13, 2020. 
 
You asked the Plan to pay for the fluoride varnish and intraoral periapical x-rays. You say that you would like 
the services covered. The Plan denied your request. The Plan says you have met frequency limits for the x-rays 
and the fluoride varnish is not covered under your 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. The Plan does not cover 
fluoride varnish. The Plan covers intraoral periapical x-rays once per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation that they have covered one 
intraoral periapical x-ray on November 13, 2020. Based on this information, we decided that the Plan does not 
have to pay for the topical application of fluoride varnish (D1206) and intraoral periapical radiographic images 
(D0230) provided November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair and accessories to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the wheelchair and accessories. The Plan denied your request. The Plan says 
in-network providers are available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the wheelchair and accessories to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) and addition to lower extremity 
orthosis, suspension sleeve (L2397) provided October 13, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you are requesting the plan to review the denial of 
claim for services rendered on October 13, 2020 by submitting documentation for review. The Plan denied 
your request. The Plan says the records do not support the billed service and the provider is not a Medicare 
certified DME supplier and not eligible to receive payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The delivery ticket submitted did not include 
the carrier's tracking number. The proof of delivery did not include an order number or details to corroborate 
the delivery ticket submitted and the proof of delivery is not itemized to indicate the specific supplies. 
 
 The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and addition to lower 
extremity orthosis, suspension sleeve (L2397) provided October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS unit for the enrollee. 
 
You asked the Plan to pre-approve the unit. You say that the enrollee's diagnosis of cervicogenic and tension 
headaches would benefit from this request. The Plan denied your request. The Plan says the clinical 
documentation does not show that the pain has been present for at least three months, and other treatment 
modalities have been tried and failed. 
 
The Plan must follow Medicare rules. Medicare rules say that the TENS unit is not considered to be reasonable 
and necessary for headaches. 
 
The enrollee's diagnosis of headaches is not considered reasonable for this request. Based on this information, 
we decided that Medicare rules for coverage of the unit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a TENS unit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) for the enrollee. 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 a HFCWOD. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found there is no evidence 
of cystic fibrosis, neuromuscular disease, or bronchiectasis documented on chest CT scan. Medicare does not 
cover the requested device for the treatment of chronic obstructive pulmonary disease. This device is not 
considered medically 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) provided October 13, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the records do not support the billed 
service. The provider is not a Medicare certified DME supplier and is not eligible to receive payment. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. The record does not contain a valid physician order, proof of delivery, or relevant 
medical records which support medical necessity for the supplies provided in this case. In this case the delivery 
ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order 
number or details to corroborate the delivery ticket submitted and the proof of delivery is not itemized to 
indicate the specific supplies. There is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis 
(L1833) provided October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care skin substitute grafts. 
 
You asked the Plan to pre-approve Revita, per sq cm (Q4180), Application of skin substitute graft to trunk, 
arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (15271), 
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each 
additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary 
procedure) (15272). You say that the enrollee has had wound care that has failed, and you want to try this 
methodology. The Plan denied your request. The Plan says the enrollee has not failed response to standard 
wound care. 
 
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 Revita, per sq cm (Q4180), Application 
of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less 
wound surface area  (15271), Application of skin substitute graft to trunk, arms, legs, total wound surface area 
up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to 
code for primary procedure) (15272). Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found in this case the medical record 
documentation does not indicate why Revita skin substitute is required. The medical reasonableness and 
necessity of the requested service is not established.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita, per sq cm (Q4180), Application of skin substitute graft to trunk, arms, 
legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area  (15271), Application 
of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm 
wound surface area, or part thereof (List separately in addition to code for primary procedure) (15272) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve wound care skin substitute grafts.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
14, 2020 by you, an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee has no choice in 
the medical professional they are seen by while in the facility. You also say that you rely on the facility to 
obtain any necessary authorization. The Plan denied your request. The Plan says you are not an in-network 
provider, and there is no authorization on file. 
 
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 
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 subsequent nursing facility care provided on 
September 14, 2020 by you, an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 6, 7, 8, 9, 10, and 11 and 
retainer crowns (D6740) for tooth #'s 5 and 12. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like the bridge to 
be approved. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 pontics 
and retainer crowns 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 pontics and retainer crowns. Our 
reviewer says that a fixed prosthesis replacing tooth #'s 6 to 12 does not meet the criteria for coverage in this 
case. Our physician reviewer found your dental record and radiographs indicate that the abutment retainers 
would lack the adequate support for a fixed bridge. Ante's Law states that "the total periodontal membrane area 
of the abutment teeth must equal or exceed that of the teeth to be replaced." In this case this does not appear to 
be the case. Our reviewer also found that a removable prosthesis would be customary for the replacement of 
these teeth. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6245) for tooth #'s 6, 7, 8, 9, 10, and 11 and retainer crowns 
(D6740) for tooth #'s 5 and 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nebulizer (HCPCS E0570) provided to the enrollee on July 
23, 2020. 
 
You asked the Plan to pay for the nebulizer. You say that this should be paid for. The Plan denied your request. 
The Plan says this was billed with an invalid or missing modifier. 
 
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 E0570 is "Nebulizer, with compressor." 
 
We asked our coding 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 nebulizer. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found medical 
equipment should be billed with the appropriate modifier to identify it as a rental. 
 
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 nebulizer have not been met. Therefore, we decided that the Plan does not 
have to pay for a nebulizer (HCPCS E0570) provided to the enrollee on July 23, 2020.