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

We decided that the Plan has to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the requested procedure is not supported for the treatment of the enrollee's pain.
The Plan follows Medicare rules. Medicare rules say that facet joint radiofrequency neurotomy is only covered under certain medical indications. 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 services. Our physician reviewer found that you have chronic low back pain and are status-post spine surgery. You have tried and failed conservative therapy including physical therapy, chiropractic therapy, and a home exercise program. You are on Gabapentin, Oxycodone, Flexeril, Ibuprofen and Flector patch. You had 2 separate sessions of medial branch blocks, and achieved 80% pain relief each time. The request is for radiofrequency ablation (RFA). The plan notes a non-standard RFA procedure, but there is nothing in the notes to suggest that a non-standard approach is being used here. Therefore, the requested procedure is medically 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 services have been met. Therefore, we decided that the Plan has to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringes.You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary due to severe osteoporosis.The Plan denied your request. The Plan says there must be a failed trial of bisphosphonates such as alendronate before drugs like Prolia will be considered.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 Prolia. Our reviewer says that rules for coverage have not been met. Our physician reviewer found the plan requires a documented, failed trial of oral bisphosphonate therapy before alternatives will be considered. The record does not show any trial of bisphosphonates or any reason why they would be ineffective or unsafe for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus and diphtheria (TD) vaccination provided on July 23, 2019.
You asked the Plan to pay for immunization. You say that your doctor asked you to get this vaccine because
you had not had one in over 10 years. The Plan denied your request. The Plan says the denial of payment for
this service is correct, because this vaccine is not covered by Medicare Part B and may be covered by your
Medicare Part D prescription drug benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to immunization.
Therefore, we decided that the Plan does not have to pay for tetanus and diphtheria (TD) vaccination provided
on July 23, 2019.
Benefits for immunization may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forneuromonitoring services (95941) provided on July 9, 2019. .You asked the Plan to pay forthe neuromonitoring services. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says code 95941 is not recognized by Medicare.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.We find that CPT code 95941 is not supported in the medical record. Specifically, The Centers for Medicare & Medicaid Services Physician Fee Schedule shows code 95941 marked with an "I". This means the code is invalid for Medicare purposes and cannot be paid. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay forneuromonitoring services (95941) provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 15, 2019 by out of network provider.
You asked the Plan to pay for office visit. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 has network providers available who can provide 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 medical services provided on July 15, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation of an anti-microbial drug (87186) provided on June 1, 2019 by out of network provider.
You asked the Plan to pay for evaluation of an anti-microbial drug. You say that you are asking a plan to approve the services and reprocess the claim for payment. The Plan denied your request. The Plan says the member sought non-emergent/urgent services on his own with a non-contracting provider and did not allow the primary care physician (PCP) to request approval from the Health Plan which would have advised him where to seek 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 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 has network providers available who can provide 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 evaluation of an anti-microbial drug (87186) provided on June 1, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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-approve Oxycodone-Acetaminophen.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 31, 2019 through February 7, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 31, 2019 through February 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee's partial denture is bent and no longer fits. The Plan denied your request. The Plan says the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and partial dentures are a covered service, the frequency limit has been reached. The record shows that the enrollee last received a maxillary partial denture on December 17, 2018 and paid by the Plan on January 4, 2019. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that this should be covered. The Plan denied your request. The Plan says you have already been diagnosed with sleep apnea and the records do not indicate this is 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 sleep study. Our reviewer says that the requested sleep study is not considered medically reasonable and necessary in this case. Our physician reviewer found you have been diagnosed with sleep apnea in the past. The documentation does not demonstrate that a repeat sleep study is medically reasonable and necessary. There is no documentation of when the diagnosis of sleep apnea was made, and what the results of the previous sleep study were. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided to the enrollee on September 10, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 ankle foot orthosis (L1971) provided to the enrollee on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the insert to treat Tenosynovitis. 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 pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that staff at the senior living facility had called for the ambulance and the enrollee then refused transportation to the hospital. The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 30, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a breast prosthesis described by L8035 is denied as not medically necessary. The item at issue is a custom breast prosthesis described by procedure code L8035. Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says neither Medicare nor your Medicare Advantage health plan covers this item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve dispensing fee, unspecified hearing aid (CPT Code V5090), for the enrollee.
You asked the Plan to pre-approve the hearing aid. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says that this request is denied because this provider does not participate with our plan, as there are participating providers associated with participating facilities that can perform or supply this requested service.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have been met. The hearing aid benefit is not a Medicare benefit. It is a supplemental benefit offered by the plan that reimburses $1,000 every three years for hearing aids for both ears combined. This means that the generic lock-in language in Chapter 3 is not sufficient. The limitation on a plan provider must be specifically listed for the hearing aid benefit. It is not, neither in the hearing aid section of the benefits chart (Chapter 4) nor in the exclusions list at the end of the benefit chart. There is no mention of using specific providers in the EOC for the hearing aid benefit. Therefore, we decided that the Plan has to pre-approve dispensing fee, unspecified hearing aid (CPT Code V5090), for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide 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 Stelara 45mg/0.5 mL (J3357).
You asked the Plan to pre-approve Stelara 45mg/0.5 mL. You say that the medication is necessary. The Plan denied your request. The Plan says that criteria for self-administered drug coverage has not been met.
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-approve Stelara 45mg/0.5 mL (J3357).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Echocardiography (93313) provided on January 23, 2019.
You asked the Plan to pay for the Echocardiography. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says modifiers 26 & TC cannot be used with this
code.
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 93313 is not supported in the record. Specifically, CPT 93313 has a PCTC indicator of 0. This means that this is a physician service and modifiers 26 and TC cannot be used. Based on this
information, we decided that Medicare rules for coverage of the Echocardiography have not been met.
Therefore, we decided that the Plan does not have to pay for Echocardiography (93313) provided on January
23, 2019.
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 need intense therapy and the nursing home does not have the right physical therapy program to help your leg. You say that you were not given the proper care for your medical condition when you previously were admitted to the skilled nursing facility. The Plan denied your request. The Plan says the criteria have not been met for IRF care. The plan says that the enrollee's needs can be safely met at a lower 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 the enrollee's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She is ambulating household distances. She has a unilateral right lower extremity impairment without identified significant upper extremity impairment with a prior history of right lower extremity impairment since her original injury and surgery. The enrollee is limited by pain and decreased strength. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility level. 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.