Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe thoracic-lumbar-sacral orthosis provided on July 10, 2020.You asked the Plan to pay forthe thoracic-lumbar-sacral orthosis (L0457). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the orthosis is not supported in the medical records received.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 thoracic-lumbar-sacral orthosis (L0457). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was back pain, as well as knee pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back.
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 thoracic-lumbar-sacral orthosis (L0457) have not been met.Therefore, we decided that the Plan does not have to pay forthe thoracic-lumbar-sacral orthosisprovided on July 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea genicular nerve block for the enrollee.You asked the Planto pre-approvethe block. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered experimental and investigational.The Planmust 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 wascorrect in denying the request to pre-approve the block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve blocks 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 the block have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea genicular nerve block for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex Superion spacer device.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lackof evidence to support that this device is safe and effective.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 spacer remains experimental. More research is needed to show safety and efficacy. Open laminecectomy is the gold standard procedure.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 pre-approvethe Vertiflex Superion spacer device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you are requesting additional routine transportation trips.The Plan denied your request. The Plan says you have used this benefit by receiving a total of ten (10) one-way trips.Medicare does not covertransport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 13th trip and beyond is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex implant.
You asked the Plan to pre-approve Vertiflex implant. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 Vertiflex implant. 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 chronic lower back pain with radiation to bilateral lower extremities.
The requested device is experimental. More research is needed to show safety and efficacy. Therefore, the
enrollee does not meet criteria for the requested 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 Vertiflex implant have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex implant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided by a facility on April 6, 2020.You asked the Plan to pay forself-administered drugs under Medicare Part B. You say that this claim should be paid by the Plan.The Plan denied your request. The Plan says payment for self-administereddrugs is submitted to Medicare Part D.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forself-administered drugs provided by a facility on April 6, 2020.Benefits for self-administered drugs may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation and intermittent BiPAP, surveillance laboratory studies, hemodialysis, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approv ehyperbaric oxygen therapy (CPT Codes: G0277 and 99183).

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 not necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found in this case, there is no specific clinical rationale for continued hyperbaric oxygen treatment. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within 
any 30-day period of treatment. The review has determined that the medical records provided do not meet the requirements listed in the NCD for Medicare coverage.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 hyperbaric oxygen therapy (CPT Codes: G0277 and 99183).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stabilink spacer device.
You asked the Plan to pre-approve a Stabilink spacer device. You say that the requested Stabilink spacer device
is medically necessary. The Plan denied your request. The Plan says the requested Stabilink spacer device is
not medically necessary.
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 Stabilink spacer device. Our reviewer
says that the requested Stabilink spacer device is not medically necessary. Our physician reviewer found the
enrollee is with a chronic history of back pain. The requested Stabilink device is experimental. More research is
needed to show safety and efficacy. It is not medically necessary 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 Stabilink spacer device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Stabilink spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.
You asked the Plan to pre-approve extractions. You say that you need this procedure for your condition. The
Plan denied your request. The Plan says the denial of authorization for these services is correct, because you
should be seen for an examination first to determine a treatment plan for the extractions.
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 extractions
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 extractions. Our reviewer says that you
do not meet the criteria for the requested extractions at this time. Our physician reviewer found the records
provided do not assess your current need for these services, and an initial examination may be necessary to
determine this need. It is necessary to have an examination in order to develop a diagnosis and then a treatment
plan. Therefore, the examination required by the Plan is a prerequisite to the requested extractions.
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 extractions have not been met. Therefore, we decided that the Plan does not
have to pre-approve dental extractions.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided.

You asked the Plan to waive the copay for the CT scan. You say that you received a lung cancer screening.The Plan denied your request. The Plan says the claim processed and paid correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copay for outpatient diagnostic services, such as CT scans. 

The file shows that you received a CT scan of the chest. You have been asked to pay $116.27 for the CT scan. Because the amount is less than the $200 copay, you were charged the lesser amount. The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous image-guided lumbar decompression services.You asked the Plan to pre-approvethe requested services. You say that the enrollee is an excellent candidate for the therapy.The Plan denied your request. The Plan says there is no indication that the enrollee is in a Medicare study.The Plan follows Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar Decompression is only covered under certain medical indications.We looked at the file, and Medicare rules. The documentation provided does not indicate that the enrollee is in a Medicare-covered clinical study. Based on this information, we decided thatMedicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvepercutaneous image-guided lumbar decompression services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and heart failure. Your medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve dermatology service. You say that you are appealing. The Plan denied your
request. The Plan says the denial of authorization for this service is correct, because this provider is out-ofnetwork
with the Plan and the enrollee can be treated by an in-network dermatologist.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 10, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. The claim was not submitted with the required codes for this service. The Plan says that Medicare Guidance says as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code. To report a CGP service, providers should use code 81479 as a bundled code for the entire bundled multi-test panel at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. If 81479 also is on the claim as coding for an unlisted service, in that use of the code it does not meet the Medicare prescribed use for a bundled code. In that case unlisted code CPT 81479 must meet the unlisted code requirement of a detailed narrative explanation on the claim or attached to the claim. 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 claim submitted is lacking the required codes as stated in the Medicare rules. Medicare billing criteria for this claim are not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for complications following recent CT surgery. The enrollee is not intubated/ventilated.There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the breast ultrasounds provided on June 17, 2020.
You asked the Plan to waive the copays for the ultrasounds. You say that the testing was part of a routine breast exam. The Plan denied your request. The Plan says you are responsible for the copay for each ultrasound.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copay for each Medicare-covered radiological diagnostic service. The file shows that you received a right and left breast ultrasound. You have been asked to pay a $110 copay for each ultrasound. The ultrasounds fall within the outpatient diagnostic tests 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 copays for the breast ultrasounds provided on June 17, 2020.