Persius/hicric huggingface dataset:
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 your podiatrist gave you a prescription for orthopedic shoes. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Group 3 Power Wheelchair with Power tilt/recline.

You asked the Plan to pay for Group 3 Power Wheelchair with Power tilt/recline. You say that you would like reconsideration because this wheelchair is medically necessary. The Plan denied your request. The Plan says the member has no current or history of pressure ulcers and does not utilize intermittent catheter.

The Plan follows Medicare rules. Medicare rules say that a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating leg rests will be covered if specific criteria are met. 

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 Group 3 Power Wheelchair with Power tilt/recline. Our reviewer says that the documentation does not reveal that the member is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed or needs a power seating system to manage increase tone or spasticity. Our physician reviewer found the documentation does not reveal that the member requires other types of proportional input devices or non-proportional input devices. The member does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices or an attendant control. The member's strength and function in the upper extremities with the ability to feed and groom himself indicates that the member can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 3 Power Wheelchair with Power tilt/recline have not been met. Therefore, we decided that the Plan does not have to pay for Group 3 Power Wheelchair with Power tilt/recline.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and counseling services provided on November 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network 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 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 home visit and counseling services provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250 x6).

You asked the Plan to pre-approve removal of residual tooth roots. You say that you cannot get your dentures until this service is completed. The Plan denied your request. The Plan says this is not listed as a covered service and is excluded from coverage.

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 removal of residual tooth roots (D7250 x6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3330) and treatment of root canal obstruction (D3331).

You asked the Plan to pay for the endodontic therapy and root canal treatment. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental 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 endodontic therapy (D3330) and treatment of root canal obstruction (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239).

You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia. You say that you would like this service to be approved for coverage for the enrollee. The Plan denied your request. The Plan says this service is not covered.

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 first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for emergency room services provided on December 19, 2020.

You asked the Plan to waive this copayment. You say that you were misdiagnosed several times by urgent care which caused you to have to go to the emergency room. You do not feel you owe the copayment. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 $50 copayment for emergency room services. 

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 $50 copayment charged for emergency room services provided on December 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted for this request does not support continuation of therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional therapy is not generally accepted as specific and effective for the enrollee's condition beyond what was approved by the health plan. The enrollee has had extensive therapy for this condition, and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee does not have a condition that is indicated for coverage.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

The records do not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that you were under the impression that these services had been approved. You say that the only thing that changed was your dentist. You say that you are seeing a new dentist at the same practice. You also say that you have been dealing with this for months. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan also says that since gingival irrigation is not listed, it is therefore excluded from coverage.

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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for all 4 quadrants.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care services.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider, which required authorization and there is not one on file.

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 services at issue. 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 subsequent nursing facility care services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 4KScore testing.

You asked the Plan to pay for the 4KScore testing.. You say that you would like reconsideration because this
testing is medically necessary and covered by Medicare. The Plan denied your request. The Plan says this
testing is not a Medicare covered benefit.

The Plan follows Medicare rules. Medicare rules say that the 4KSCORE test will be considered medically
reasonable and necessary when testing of men 45 years of age and older, prior to an initial biopsy or following
a negative biopsy, who have a confirmed moderately elevated PSA.

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 4KScore testing. Our reviewer says that
the LCD criteria for coverage for 4KScore testing have not been met. Our physician reviewer found the
medical records provided indicate that there are no palpable prostatic nodules and that a prostate biopsy has not
been performed. The PSA must be greater than or equal to 4 and less than 10 ng/mL in men greater than 75
years of age.

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 4KScore testing have not been met. Therefore, we decided that the Plan
does not have to pay for 4KScore testing.
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 services are necessary. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. You do not appear to have the endurance to tolerate intensive therapy in an IRF.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for the Tempus Gene Panel testing.

You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because this testing is medically necessary and a valuable tool in determining treatment. The Plan denied your request. The Plan says that to report a Comprehensive Genomic Profile, providers should use CPT 81479.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Tempus Gene Panel. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Molecular Diagnostic Studies in Non-Small Cell Lung Cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The NCCN NSCLC Guidelines Panel strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit.

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 Tempus Gene Panel have been met. Therefore, we decided that the Plan has to pay for the Tempus Gene Panel testing.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cardiac MRI (75561).

You asked the Plan to pre-approve the Cardiac MRI. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says there are no results for the previous cardiac MRI.

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 the Cardiac MRI. Our reviewer says that a repeat MRI scan is not medically necessary or reasonable. Our physician reviewer found the cardiac wall abnormality noted on the echocardiogram has already been assessed by the cardiac MRI with contrast, and the results are included in the notes.

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 Cardiac MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cardiac MRI (75561).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650).

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item provided was medically
necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by
the ordering physician in order to warrant the code billed.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria in the
Medicare rules section is met.

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 a lumbar-sacral orthosis. Our reviewer says
that the requested item is not medically necessary and reasonable. Our physician reviewer found an appropriate
history and a physical examination of the back would reasonably be required to adequately assess whether the
coverage criteria for a lumbar-sacral orthosis 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 an appropriate evaluation of the enrollee and 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 a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan
does not have to pay for a lumbar-sacral orthosis (L0650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a humidifier (E0562).

You asked the Plan to pre-approve the humidifier. You say that the enrollee requires the device as their space heater causes symptoms to flare. The Plan denied your request. The Plan says a humidifier is only covered when used with a respiratory assist device.

The Plan must follow Medicare rules. Medicare rules say that a non-heated (E0561) or heated (E0562) humidifier is covered and paid separately for use with a covered E0470 or E0471 Respiratory Assist Device (RAD). That is not the case for this request.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve a humidifier (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) computed tomography, lower extremity (73700) Arthrocentesis, aspiration and/or injection (20605) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that this doctor is very good at what he does. You will probably see this doctor twice a year for shots. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99213) computed tomography, lower extremity (73700) Arthrocentesis, aspiration and/or injection (20605) provided by an out of network (OON) provider.