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

We decided that the Plan does not have to pay for the compression stockings identified with code A6534 that were issued on October 19, 2020.
You asked the Plan to pay for the compression stockings. You say that you need to wear the thigh length compression stocking due to blood clots and that you have worn them for years. The Plan denied your request. The Plan says thigh length compression stocking are non-covered per the member's benefits.
The Plan must follow Medicare rules. The Medicare rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Your plan says that it will not cover services that are not considered reasonable and necessary according to the standards of Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6534 that were issued on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for COVID-19 infection. Her medical conditions are stable and she has no complex nursing or
rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program.
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral X-ray (D0220), extraction, erupted tooth or exposed root (D7140), and re-cement or re-bond crown (D2920) provided from June 24, 2020, to July 3, 2020.
You asked the Plan to pay for the intraoral X-ray, extraction, erupted tooth or exposed root, and re-cement or re-bond crown. You say that these services would be covered if you had gone to an in-network provider. The Plan denied your request. The Plan says these services are not covered under your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral X-ray (D0220), extraction, erupted tooth or exposed root (D7140), and re-cement or re-bond crown (D2920) provided from June 24, 2020, to July 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex surgery (22869, 22870).You asked the Plan to pre-approvethe Vertiflex surgery. You say that this surgery is medically necessary.The Plan denied your request. The Plan says the surgery 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 the Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device used with the Vertiflex surgery is experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex surgery (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on August 3, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you would like the Plan to pay for this service because you have paid insurance.The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received another problem focused limited oral evaluation (D0140) on August 3, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on August 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of pembrolizumab with lenvatnib.

You asked the Plan to pre-approve the pembrolizumab treatment. You say that recent findings have shown
pembrolizumab and lenvatnib can be effective for those with advanced endometrial cancer with progression
following prior systemic therapy. The Plan denied your request. The Plan says that the literature supporting this
only applies to cancer that is not MSI-H or dMMR. In this case, there is no documentation of this information.
As such, this treatment is not supported.

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 pembrolizumab treatment. Our
reviewer says that the documentation supports the medical necessity of the requested treatment. Our physician
reviewer found the enrollee has recurrent endometrial cancer after three cycles of carboplatin ending in
September 2020, followed by brachytherapy. It is found that the use of pembrolizumab is FDA-approved for
this circumstance due to failure of prior platinum-based therapy.

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 pembrolizumab treatment have been met . Therefore, we decided that the
Plan has to pre-approve use of pembrolizumab with lenvatnib.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 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 physician services provided on September 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe annual depression screening (G0444) provided on February 6, 2020.You asked the Plan to pay forthe annual depression screening. 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 record does not support the billed service.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 G0444 is annual depression screening, 15 minutes.We find that CPT code G0444 is supported in the medical record. Specifically, Medicare rules state that an annual depression screening is covered up to 15 minutes for Medicare beneficiaries in primarycare settings. The note indicated by the physician on February 6, 2020,statesthat eight minutes was spent providing this service to the enrollee. As such, the provided documentation does support the billing of CPT code G0444. Based on this information, we decided that Medicare rules for coverage of the annual depression screening have been met.Therefore, we decided that the Plan has to pay for the annual depression screening (G0444) provided on February 6, 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: Unfavorable

We decided that the Plan does not have to providea therapeutic continuous glucose monitor.You asked the Plan to providea therapeutic continuous glucose monitor. You say that the enrollee is not physically able to blood test 4 times a day.The Plan denied your request. The Plan says criteria is not met for a CGM.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 a therapeutic continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to providea therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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. Our physician reviewer found based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on September 17, 2020.
You asked the Plan to pay for foot orthotics. You say that orthotics are for treatment to reduce pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) 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 orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for transcatheter aortic valve replacement (33361) provided on August 26, 2020.
You asked the Plan to pay for the transcatheter aortic valve replacement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with a valid clinical trial number.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 33361 is not supported in the record. Specifically, this claim has not been submitted with a valid clinical trial number. Based on this information, we decided that Medicare rules for coverage of the transcatheter aortic valve replacement have not been met. Therefore, we decided that the Plan does not have to pay for transcatheter aortic valve replacement (33361) provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on January 25, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until August 28, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on January 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNurtec tab.You asked the Plan to pre-approveNurtec tab. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.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 pre-approveNurtec tab.Benefits for Nurtec tabmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 16, 2020 by a non-contracted provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-contracted provider without prior authorization.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 referring provider 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 forthe medical services provided on July 16, 2020 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs respiratory therapy.
The Plan denied your request. The Plan says the services are 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 LTACH care is not medically necessary. Our physician reviewer found the enrollee is
chronically ill, bedbound, and currently has a tracheostomy and PEG tube. The enrollee is receiving
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are
not available at the acute care hospital where he is currently receiving care. There are no services available at
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 2, 2020.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.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 drug test. 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 a drug test provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe IV tubing extension set coded S1015 and the infection control supplies coded S8301 provided on May 19, 2020.You asked the Plan to pay forthe Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set and the infection control supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe IV tubing extension set coded S1015 and the infection control supplies coded S8301 provided on May 19, 2020