Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvethe CardioMEMS device for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary.The Plan denied your request. The Plan says that that this is not covered under the current Medicare Category B Investigational Device Exemption Requirements.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. The patient has complex cardiopulmonary disease with Class III congestive heart failure, pulmonary hypertension, baseline chronic pulmonary disease and remains symptomatic at baseline with recurrent prior hospitalizations for congestive heart failure. The enrollee has had her diuretic regimen adjusted but it remains difficult to manage her fluid status using conventional (physical exam, weights) measures. CardioMEMSdevice pulmonary artery pressure measurement is FDA approved for this indication and has been shown in randomized published trials to decrease recurrent hospitalization and improve symptoms in select patients who have chronic CHF and have been hospitalized for this. The CardioMEMSis not experimental based on the FDA approval and published trials and would be considered medically necessary based on the Medicare rules governing its use in this specific clinical situation and there is both published data and expert opinion guiding its appropriate use. The patient in this instance has a very complex condition with both pulmonary and cardiac causes of her dyspnea and regular assessment of her fluid status is critical to treating her condition and keeping her out of the hospital. As this has been unsuccessful with usual methods, the CardioMEMSdevice pulmonary pressure sensor device is medically indicated to provide the necessary monitoring. Our physician reviewer found that the enrollee's condition meets Medicare criteria for 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-approvethe CardioMEMS device for the enrollee.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean abutment crown for tooth 23.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the 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 pre-approvean abutment crown for tooth 23.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second stage implant surgery.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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. The Plan covers these 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 these services. Our reviewer says that Our physician reviewer found 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve second stage implant surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no exam that confirms the pain is from the facet joints.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has several probable pain generators, and there is a lack of documentation from physical exam and imaging to support thoracic facets as the primary source of pain. The request for diagnostic thoracic MBBs is 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scaling and root planing.You asked the Plan to pre-approvethe periodontal scaling and root planing. You say that the care needed was beyond a regular cleaning, due to inadequate care in Hawaii. You say that you had to put off necessary dental work because of having three heart procedures.ThePlan denied your request. The Plan says the services in dispute are not a covered 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 coveragerules 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-approveperiodontal scaling and root planing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone replacement graft (D4263) and guided tissue regeneration (D4266).You asked the Plan to pre-approvethe bone replacement graft and guided tissue regeneration. You say that you would like to appeal these services.The Plan denied your request. The Plan says these services are not covered under your benefit package.Medicare generally does not cover dental services. However, the Planoffers 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-approvea bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a partial lower denture (D5214).You asked the Plan to pre-approvethe dental items. You say that you lost your dentures during a hospital visit.The Plan denied your request. The Plan says dentures are covered once every 5 plan years.The Plan also says that the frequency limit for these services has been reached.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 frequency limit of 1 set of dentures every 5 plan years has been reached. The record shows that the Plan paid for a complete upper denture and a partial lower denture that you received on April 29, 2019.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a partial lower denture (D5214)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SoClean machine.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea SoClean machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveanunspecified endodontic procedure (D3999) for tooth number 19.You asked the Plan to pre-approvethis service. You say that you are requesting a reconsideration of the Plan's denial.The Plan deniedyour request. The Plan says this service is not a covered benefit under the enrollee's dental policy.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 service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean unspecified endodontic procedure (D3999) for tooth number 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea gel pressure pad for a mattress (E0185).You asked the Plan to pre-approvethe gel pad. You say that you need comfort because you are unable to get any rest.The Plan denied your request. The Plan says that you do not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that a Group 1 mattress overlay or mattress is covered if you are completely immobile, have limited mobility or have any stage pressure ulcer on the trunk or pelvis.We looked at the file and Medicare rules. The file does not indicate you are completely immobile, have limited mobility or have any stage pressure ulcer on the trunk or pelvis. Based on this information, we decided that Medicare rules for coverage of the gel pad have not been met.Therefore, we decided that the Plan does not have to pre-approvea gel pressure pad for a mattress (E0185).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the casefile 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 services are not medically necessary. Our physician reviewer found Keytruda is FDA-approved for the treatment of hepatocellular carcinoma in patients who have been previously treated with sorafenib. There is no support from the medical literature or major drug compendia for off-label use. The enrollee is currently on atezolizumab and bevacizumab and there is no indication why another check point inhibitor would be indicated. The service is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator.
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you already completed an appeal and your cost share should be reduced to $4.65 per month. The Plan denied your request. The Plan says you were granted a one-time exception and that the full 20% coinsurance would apply for future claims.
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 20% coinsurance for Durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the oxygen concentrator. The oxygen concentrator falls within the Durable medical equipment and related supplies 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 oxygen concentrator (E1390) received October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic shoe (L3916).
You asked the Plan to pre-approve this item. You say that an orthopedic shoe is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy for your condition.
Medicare rules state that supportive devices for the feet (such as orthopedic shoes) 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 an orthopedic shoe may be appropriate for you, neither Medicare nor the Plan provides coverage of orthopedic shoes for your condition. Therefore, we decided that the Plan does not have to pre-approve an orthopedic shoe (L3916).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.
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 physician's services. 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 physician's services provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4557 x 2) provided on September 24, 2020.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the lead wires provided do not meet Medicare criteria for payment.

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 case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Specifically, a TENS unit has been purchased in the previous twelve months on October 24, 2019 and November 24, 2019. Medicare rules state that replacement of lead wires more often than every twelve months would rarely be reasonable and necessary. Additional records have not been provided to support the medical necessity of the additional lead wires provided. Therefore, we decided that the Plan does not have to pay for the lead wires (A4557 x 2) provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 29, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services are available in-network.

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 physician's services. 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 physician's services provided on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean air-fluidized bed (E0194) and an over bed table (E0274).You asked the Plan to pre-approvean air-fluidized bed and an over bed table. You say that you need these items.The Plan denied your request. The Plan says these items are not covered for your condition.The Plan must follow Medicare rules. Medicare rules say that an air-fluidized bed is covered only if the beneficiary has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer. An over bed table is noncovered because it is not primarily medical in nature.We looked at the file and Medicare rules. The submitted medical records do not show that you have an ulcer that qualifies for an air-fluidized bed. The requested over bed table is not covered. Based on this information, we decided that Medicare rules for coverage of an air-fluidized bed and an over bed table have not been met.Therefore, we decided that the Plan does not have to pre-approvean air-fluidized bed (E0194) and an over bed table (E0274).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vita Risk testing rendered on December 23, 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 the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of non-exudative age-related macular degeneration. There is insufficient data demonstrating clinical utility impacting health outcomes for the testing at issue. The testing was not reasonable or medically necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Vita Risk testing rendered on December 23, 2019. LCD L35000 referenced by the Plan is for the wrong jurisdiction and was not used in the determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical tooth extraction for tooth 5.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the request exceeds the benefit limit.
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 two tooth extractions per calendar year. We looked at the file and the Plan's rules. The file shows that you were approved for two tooth extractions on January 5, 2021. Further extractions are not covered by your supplemental benefit or your medical benefit. The services are not covered by the medical benefit because the extractions are not being done to prepare the jaw for radiation treatments. Therefore, we decided that the Plan does not have to pre-approve surgical tooth extraction for tooth 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forpneumatic compression device (E0651, E0667) provided to the enrollee on July 20, 2020.You asked the Planto pay forthe device. You say that the medical records support the payment of the denied codes.The Plandenied your request. The Plansayspneumatic devices are covered only for the treatment of lymphedema orfor the treatment of chronic venous insufficiency with venous stasis ulcers.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 device. Our reviewer says that the device at issue in this case is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal objective evidence of a four-week trial of conservative therapy demonstrating failed response to treatment. There is no objective documentation of a four-week trial of conservative therapy with detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. There are no objective physical exam findings of lymphedema including: marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica,deformity of elephantiasis, or skin breakdown with persisting lymphorrhea.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 Plandoes not haveto pay forpneumatic compression device (E0651, E0667) provided to the enrollee on July 20, 2020