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

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical and lumbar spine (72141, 72148).
You asked the Plan to pre-approve the MRI's. You say that the MRI's are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
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's. Our reviewer says that the MRI's are medically necessary. Our physician reviewer found the record indicates that the enrollee has known lumbar stenosis and had undergone previous lumbar surgery. The enrollee has lower extremity neuropathy. Examination demonstrates cervical radiculopathy. Pharmacologic treatment has not been successful. The enrollee is limited in physical activity. The records support the need for the MRI imaging. 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's have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical and lumbar spine (72141, 72148).
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-approve Provenge treatments.
You asked the Plan to pre-approve the requested Provenge treatments. You say that this is medically necessary as his bone metastases have progressed in spite of Lupron treatment. The Plan denied your request. The Plan says the enrollee's disease is not considered castrate resistant at this time.
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 case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested Provenge treatments. Our reviewer says that the documentation does not support that the use of this drug is medically reasonable and necessary at this time. Our physician reviewer found the enrollee has a history of prostate cancer with addition of Lupron in December 2020. His prostate-specific antigen (PSA) levels have fallen from the teens to single digits in this time. The testosterone level is considered castrate. There is some increase in bone metastases on recent computed tomography (CT) imaging. At this time, it is not felt there is sufficient evidence to determine his disease is castrate-resistant which is required for the use of Provenge. His PSA has fallen, and CT imaging is not the ideal way to assess for progression of bone metastases, as the changes noted could be due to healing lesions. Based on the information available at this time, the use of Provenge is not considered reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested Provenge treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Provenge treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle test strips.
You asked the Plan to pre-approve Freestyle test strips. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). 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 Freestyle test strips. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not state why the enrollee cannot use the preferred strips. The precision neo strips are used with the freestyle libre continuous glucose monitor (CGM) system as a way to confirm the cgm reading with a finger stick reading. Although this is a convenience such that the enrollee need not carry a separate meter, it is not, in most cases, medically necessary. Without more data to state why the preferred strips would not suffice, there is no evidence for coverage of the neo strips. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle test strips.
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and extraction (D7140) provided on November 10, 2020.
You asked the Plan to pay for the exam and extraction. You say that you could not find a provider who was able to provide the care you needed, and this was the first and only provider you found who was available. The Plan denied your request. The Plan says these services are covered; however, because you used an out-of-network provider, you are responsible for the difference between the provider's charges and what the Plan pays for services. These claims were processed correctly. The Plan also says that they do not have a record of you contacting the Plan to verify benefits or locate an in-network provider prior to services, and this care could have been provided in-network.
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 rules also 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 may be billed for any amount greater than the Plan's maximum allowable charge for dental services received from an out-of-network provider.
You have been asked to pay $221 for both the exam and the extraction provided on November 10, 2020. The provider billed the Plan a total of $310, but the Plan's maximum allowable charges for both services comes to $89. Because you used an out-of-network provider, you may be billed for any amount greater than the Plan's maximum allow able charge for these services ($310 - $89 = $221). 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 pay for the limited oral evaluation (D0140) and extraction (D7140) provided on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) provided on October 1, 2020.
You asked the Plan to pay for CGM supplies. You say that the records support the billing of this item. The Plan denied your request. The Plan says sufficient information to support this item was not submitted.
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. As a general Medicare rule, the date of service shall be the date of delivery. Exceptions are made for suppliers who use a delivery/shipping service. If the supplier uses a delivery/shipping service, the supplier may use the shipping date as the date of service on the claim. The record does not contain a valid proof of delivery for the supplies provided in this case. The supplies at issue were billed for a date of service of October 1, 2020, but the record shows a shipping date of October 2, 2020, and a delivery date of October 6, 2020. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services rendered on September 4, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pathology services rendered on September 4, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bariatric surgery (43846).
You asked the Plan to pre-approve the bariatric surgery. You say that the gastric bypass is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that this procedure is covered for Medicare beneficiaries who have a body-mass index greater than 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. 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 bariatric surgery. Our reviewer says that the requested procedure is medically necessary. Our physician reviewer found the records indicate that the enrollee has morbid obesity and has sleep apnea. The enrollee has tried and failed several physician-guided treatment plans for weight loss. The elements of the coverage rule are satisfied. 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 bariatric surgery have been met. Therefore, we decided that the Plan has to pre-approve bariatric surgery (43846).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on October 6, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that outpatient rehablitation claims must include one of the GN, GO, or GP modifiers.
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required GN, GO, or GP modifiers. 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 physical therapy services rendered on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (E0466).
You asked the Plan to pre-approve the home ventilator. You say that the claim should be paid. The Plan denied your request. The Plan says the denial for a Home ventilator (E0466) which is a mechanical ventilator with functionality that exceeds that of an E0470 or E0471 device, is consistent with Medicare regulations.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our 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 home ventilator. Our reviewer says that the service is not medically necessary. Our reviewer found there is no recent clinical details that confirm failure with the use of a BIPAP (E0471) device.
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does not have
to pre-approve the home ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99284) provided on October 11,
2020.
You asked the Plan to pay for an emergency room visit. You say that the enrollee was seen twice. The Plan
denied your request. The Plan says this is not separately payable without a 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, we have confirmed that code 99284
has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an emergency room visit (99284) provided on October 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 2, 2020.
You asked the Plan to pay for CxBladder testing. You say that this test is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says this test is not covered by Medicare and is considered investigational and non-covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing code 0012M is non-covered by Medicare for date of service December 2, 2020. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical supplies for a CGM (K0553).
You asked the Plan to pre-approve the medical supplies for a CGM. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the member's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above.
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 medical supplies for a CGM. Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient is not checking blood glucose levels four times a day nor is the insulin doses taken three times a day adjusted based on the blood glucose data. 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 medical supplies for a CGM have not been met. Specifically, the patient does not meet the criteria for a CGM, and therefore, the medical supplies for a CGM are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the medical supplies for a CGM (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensors for the enrollee.
You asked the Plan to pre-approve the sensors. You say that the enrollee needs the monitor because she is
hesitant to check her blood glucose due to finger pokes. The Plan denied your request. The Plan says that the
enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle
Libre 2 sensors for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a stabilizing or separating device the into lower spine.
You asked the Plan to pre-approve insertion of a stabilizing or separating device the into lower spine. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 insertion of a stabilizing or separating device the into lower spine. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process stabilizing devices are experimental. More research is needed to show safety and efficacy of the devices.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a stabilizing or separating device the into lower spine have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a stabilizing or separating device the into lower spine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on
December 10, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies
coverage for all cardiovascular risk assessment tests - except the basic lipid panel - for symptomatic patients
with suspected or documented cardiovascular disease.
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover
these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 14, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because there is no evidence
of a relationship between the enrollee and the ordering physician to support a valid lab order.
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.
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. Therefore, we decided that the Plan does not have to pay for laboratory testing provided
on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve surgery to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 surgery to be provided by an out of network (OON) provider.