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

We decided that the Plan has to pre-approvea dermatology consultation visit.You asked the Plan to pre-approvedermatology visit. You say that you need to be treated for your rashes because you have been losing sleep due to the discomfort.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this visit is not medically necessary, and you should return to your primary care physician for further evaluation, treatment, and a discussion of options.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 dermatology visit. Our reviewer says that you meet the Medicare criteria for a dermatology consultation. Our physician reviewer found the records indicate you have seborrheic keratosis. Your primary care physician has requested this referral for evaluation and treatment and has not instituted any treatment. The requested service is 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 dermatology visit have been met.Therefore, we decided that the Plan has to pre-approvea dermatology consultation visit.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyepti.
You asked the Plan to pre-approve Vyepti. You say that you believe it is unethical to require two doses of Botox before an infusion that requires only one IV. The Plan denied your request. The Plan says the enrollee must have a trial and failure of Botox injections.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vyepti. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the Plan requires a trial of two doses of Botox injections before they will approve the requested drug. The medical records provided do not provide a sufficient medical rationale why the Plan's required drug is not appropriate for the enrollee or would have an adverse effect upon 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 Vyepti have not been met. Therefore, we decided that the Plan does not have to pre-approve Vyepti.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an all-lower extremity prosthesis, shank foot system with vertical loading pylon (L5987) and all endoskeletal lower extremity prosthesis, axial rotation unit (L5984).
You asked the Plan to pre-approve the advanced root and rotational unit. You say that the enrollee is motivated to utilize a prosthesis in order to restore his physiological capabilities he had prior to amputation surgery. You have evaluated this enrollee and have determined that they are a K3 level ambulator. The Plan denied your request. The Plan says that the request for K3 feet does not meet Medicare criteria as reasonable and necessary.
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 the advanced root and rotational unit. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation explicitly describes the enrollee as a K3 level ambulator and the specific elements that define the enrollee as a K3 level ambulator are included in the medical record progress notes. These includes the enrollee's mobility level, activities performed, as well as expectations. All coverage criteria met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the advanced root and rotational unit have been met. Therefore, we decided that the Plan has to pre-approve an all-lower extremity prosthesis, shank foot system with vertical loading pylon (L5987) and all endoskeletal lower extremity prosthesis, axial rotation unit (L5984).
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: 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 service is a necessity for your care. 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 requested procedure is considered experimental/investigational at this time. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (Current Procedural Terminology (CPT) code G0483) provided to the enrollee on September 24, 2020, by an out-of-network provider.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing (Current Procedural Terminology (CPT) code G0483) provided to the enrollee on September 24, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill
or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee from December 15,
2020, through December 17, 2020.

You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99291 is not supported in the medical record. Specifically, Current Procedural
Terminology (CPT) code 99291 (1 Unit) remains not supported for December 15, 2020, December 16, 2020,
and December 17, 2020. The documentation submitted did not support a critical care visit of 30-74 minutes
was performed on the billed date of service. The documentation does not include the time spent providing this
service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that
multiple attempts were made to contact the provider for additional information. Based on this information, we
decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that
the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically
injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee from December 15, 2020,
through December 17, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for x-rays of the hip and pelvis (73501, 73502) performed
by an out of network provider on October 23, 2020.
You asked the Plan to hold you harmless for x-rays of the hip and pelvis. You say that you are on a fixed
income and really cannot take on any more bills. The Plan denied your request. The Plan says that the out of
network deductible was correctly applied.
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 does not say in clear and accurate terms
how much you should expect to pay for basic radiological services received from an out of network provider.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $198
deductible for basic radiological services received from an out of network provider. The Plan contract does not
clearly say how much enrollees must pay for basic radiological services received from an out of network
provider. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.
Therefore, we decided that the Plan has to hold you harmless for x-rays of the hip and pelvis (73501, 73502)
performed by an out of network provider on October 23, 2020.
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: Favorable

We decided that the Plan has to pre-approve use of a Sinuva implant.
You asked the Plan to pre-approve Sinuva. You say that it is in the best interests of the enrollee to use this treatment. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because Sinuva is considered investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Sinuva. Our reviewer says that the enrollee meets the Medicare criteria for Sinuva. Our physician reviewer found the requested use of Sinuva is Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Sinuva is a corticosteroid-eluting implant indicated for the treatment of nasal polyps in patients 18 years of age or older who have had ethmoid sinus surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sinuva have been met. Therefore, we decided that the Plan has to pre-approve use of a Sinuva implant.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair, transfer bench for shower (E0247).
You asked the Plan to pre-approve a shower chair. You say that you are in a wheelchair full time and cannot transfer from the wheelchair to the shower. You are unable to lift your leg over and into the shower or stand in the shower The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair, transfer bench for shower (E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding wheeler walker (E0143).
You asked the Plan to pre-approve a folding wheeler walker. You say that you need the requested item because you are constantly falling due to lack of strength in your legs. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a written order/prescription from the treating practitioner. The record does not contain a valid physician order for the supplies requested in this case. 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 pre-approve a folding wheeler walker (E0143).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 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 procedure code 87150 is not supported.
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 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
We find that CPT code 87150 is not supported in the medical record. Specifically, there is no documentation of culture typing for identification by nucleic acid. 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 laboratory services rendered on November 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral facet block injections.You asked the Plan to pre-approvebilateral facet block injections. You say that this service is medically necessary to treat the enrollee's pain.The Plan denied your request. The Plan says there is no evidence that the member's pain improved after diagnostic facet joint blocks.The Plan follows Medicare rules. Medicare rules say that therapeuticfacet joint proceduresare only coveredafter diagnostic facet joint procedures have been performed. 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 bilateral facet block injections. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer foundthatin this case, the enrollee has low back pain with radiculopathy. There is tenderness over the thoracic and lumbar facets. The record indicates that diagnostic blocks have not been performed. The elements of the coverage criteria are not satisfied.  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 bilateral facet block injections have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral facet block injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of spinal canal scar tissue, multiple sessions
in 1 day (62264).

You asked the Plan to pre-approve the removal of spinal canal scar tissue. You say that this service is
medically necessary. The Plan denied your request. The Plan says this service is considered
experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the removal of spinal canal scar tissue.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the requested procedure is considered experimental for neck pain
treatment. More research is needed to show safety and efficacy of the procedure before this procedure will be
covered.

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 removal of spinal canal scar tissue have not been met. Therefore, we
decided that the Plan does not have to pre-approve the removal of spinal canal scar tissue, multiple sessions in
1 day (62264).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been
met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the
requested drug is not medically necessary. Our physician reviewer found that the enrollee has not had prior
therapy with Visco-3, Gel-One, Orthovisc, Synvisc, or Synvisc-One. The request for Euflexxa does not meet
the first step requirement and therefore the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard DNA stool testing (81528).
You asked the Plan to pre-approve the Cologuard. You say that this is necessary because your father died from
colon cancer, so you are supposed to have these tests done routinely. The Plan denied your request. The Plan
says this request exceeds the benefit allowable of once every 3 years.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This service is covered once every 3 years. The records show that the benefit for this service is not available until October 2022. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cologuard have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard DNA stool testing (81528).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a general surgery consultation visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you have been in pain for many years and want the best possible treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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 a general surgery consultation visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you want to go out-of-network because you have had issues with the in-network hospital. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 an outpatient surgery to be provided by an out of network (OON) provider.