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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRIs) of the shoulders and lumbar spine.You asked the Plan to pre-approve MRIs. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for the requested MRIs is correct, because physical therapy should be tried to improve the enrollee's symptoms before considering further imaging.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRIs. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRIs. Our physician reviewer found studies were previously denied because there was no detailed examination of either shoulder and there was no evidence of impingement or instability of the shoulders. Aside from diminished range of motion and discomfort, there were no other abnormalities of the lower spine. There were no red flag symptoms such as reflex abnormalities or weakness, nor was there any attempt at conservative treatment with physical therapy for any of these problems. Therefore, the requested MRIs are not medically reasonable and 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 MRIs have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRIs) of the shoulders and lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Escitalopram for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has major anxiety and insomnia.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveEscitalopram for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAvastin along with Carboplatin/Alimta/Keytruda.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe off-label use of this drug for this condition is not medically accepted.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the drug. Our reviewer says that the additional requested drug -Avastin -is not medically reasonable or necessary. Ourphysician reviewer found the drug is FDA-approved for the enrollee's diagnosis, but not in combination with immunotherapy.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveAvastin along with Carboplatin/Alimta/Keytruda.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for  genetic testing. You say that this testing is covered by Medicare, and you are the only provider of this testing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare, the 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 did not pre-approve the item/service at issue, which is required for all genetic testing whether that testing is provided by an in-network or out-of-network provider. 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 September 3, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).
You asked the Plan to pre-approve the incisional biopsy of oral tissue. You say that this procedure is necessary to determine if there is a possibility of a more serious issue such as oral cancer. You also say that denial of this procedure puts you in tremendous risk of a more potentially serious health risk. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 pre-approve an incisional biopsy of oral tissue (D7286).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a portable oxygen concentrator.
You asked the Plan to pre-approve the battery. You say that this is medically necessary. The Plan denied your request. The Plan says this is a duplicate item and not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Additionally, the item being requested is considered duplicative. Therefore, we decided that the Plan does not have to pre-approve a backup battery for a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not a covered 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 pre-approvea core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo tablets.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee needs this drug.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveLivalo tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 28, 2019.
You asked the Plan to pay for the services. You say that the claim was billed correctly with the correct modifier. The Plan denied your request. The Plan says this claim requires a modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 00910 is "Anesthesia for transurethral procedures (including urethrocystoscopy)." 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 services. Our reviewer says that the services at issue in this case were not billed correctly. Our physician reviewer found according to the medical records the pre-anesthesia evaluation was done by a nurse practitioner (NP) on 6/26/2019 and co-signed on 6/28/2019. According to the anesthesiology record (illegible in several portions of the record) anesthesia services were rendered by the CRNA. Only one billing sheet/remittance should be provided for the urology precedures performed on the date of service (6/28/2019). If the anesthesiologist is providing medical direction of one CRNA modifier QY should be used. If the anesthesiologist is providing medical direction of 2, 3, or 4 concurrent anesthesia procedures, modifier QK is appropriate for billing. It is unclear which modifier should be used for this claim. However, in either event, there should only be one (1) anesthesiology bill/1 claim submitted for the transurethral procedures performed. The medical records do not show that two separate anesthesia services were done on 6/28/2019. 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 pay for anesthesia services provided to the enrollee on June 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve a tier exception for Beovu 6mg for the enrollee.You asked the Plan to pre-approve the tier exception. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit, because the drug requested is not covered under Medicare Part D.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs.The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Beovu 6mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (D0470).You asked the Plan to pre-approve the diagnostic casts. The Plan denied your request. The Plan says diagnostic casts is not listed as a covered service.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 diagnostic cast is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (D0470).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary for you to be able to return to living independently again.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have a tracheostomy tube, complex daily wound care or other SNF level skilled nursing need. Your functional level does not require daily skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hypoglossal Nerve Stimulator and implantation procedure.
You asked the Plan to pre-approve Hypoglossal Nerve Stimulator and implantation procedure. You say that your physician says you meet all the clinical criteria for this procedure. The Plan denied your request. The Plan says at this time the request is not covered by Medicare for any reason.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hypoglossal Nerve Stimulator and implantation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Hypoglossal Nerve Stimulator and implantation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Contour Next glucose monitor and test strips.You asked the Plan to pre-approve the non-preferred brand of monitor and test strips.You say that the Contour Next meter is much more accurate.The Plan denied your request. The Plan says an exception must be considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of monitor and test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve a Contour Next glucose monitor and test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis for enrollee.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of limited metastatic (supraclavicular lymph node) cervix cancer. A PET scan was approved to determine treatment response to chemotherapy. The pelvis MRI is being requested to determine if the enrollee would be a candidate for radiation, which is a treatment planning request. Treatment planning requests do not require diagnostic imaging studies. The MRI is therefore not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis for enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve a wig. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. In this case, although the wig may be appropriate for you, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4273).
You asked the Plan to pre-approve the dental service. You say that you received this same procedure last year. You say that you were advised by a plan representative that your plan was staying the same for 2020. You also say that you were given the wrong information. The Plan denied your request. The Plan says autogenous connective tissue graft procedure is not listed as a covered service.
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 dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4273).
Your complaint about being misinformed by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued used of a bilevel positive airway pressure device (BiPAP).
You asked the Plan to pre-approve continued BiPAP device. You say that The Plan denied your request. The Plan says that you have not been compliant with usage. The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The compliance report included with the file indicates you did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued BiPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued used of a bilevel positive airway pressure device (BiPAP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says that the enrollee does not meet criteria for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.
We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day or testing blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950).You asked the Plan to pre-approve the core buildup. You say that an amalgam filling will not be strong enough. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered 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 pre-approve the core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G limb orthosis (L8702).You asked the Plan to pre-approve the orthosis. You say that the enrollee has fully exhausted the potential benefits of traditional rehabilitation and less sophisticated medical devices before being recommended for the MyoPro.The Plan denied your request. The Plan says this item is not covered by Medicare nor theplan. Medical studies have not proven that the use of the product is helpful for treatment of the enrollee's health  problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  The rules also say that experimental and investigational devices are not covered.  Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G limb orthosis (L8702).