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

We decided that the Plan does not have to pay for molecular diagnostic infectious disease testing provided on October 25, 2019.You asked the Plan to pay for the molecular diagnostic infectious disease testing. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 molecular diagnostic infectious disease testing provided on October 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolic acid DR 360mg 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 a tier exception cannot be granted for a Part B medication. 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 Mycophenolic acid DR 360mg for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vagus nerve stimulator (VNS) replacement (64568, 95977, 61885, 95976).
You asked the Plan to pre-approve a VNS replacement. You say that this is a medically necessary service that has been proven effective. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that VNS is not reasonable and necessary for resistant depression. We looked at the file and Medicare rules. The record indicates that the services at issue have been requested to treat the enrollee's depression. This is not a covered indication under Medicare rules. Based on this information, we decided that Medicare rules for coverage of a VNS replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a vagus nerve stimulator (VNS) replacement (64568, 95977, 61885, 95976).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for wound care services provided from June 4, 2019 to June 25, 2019.
You asked the Plan to pay for wound care. You say that the services were ordered by the nursing facility. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the need for service was not unforeseen and these services were not urgent/emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 wound care. Our reviewer says that these services meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could not have foreseen the need for these services. These services were medically necessary. It would not have been reasonable to delay care until the enrollee returned to the Plan's service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound care have been met. Therefore, we decided that the Plan has to pay for wound care services provided from June 4, 2019 to June 25, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left bunion correction, metatarsal osteotomy, and hardware removal for the enrollee.
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 that the services are not medically necessary. 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 pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has well-documented painful hallux valgus, confirmed both on physical examination and on x-ray findings. When findings such as these are noted, a bunion correction is certainly considered medically necessary and standard of care. To correct a significant bunion, a metatarsal osteotomy must be performed. In order for a metatarsal osteotomy to be performed, prior placed metatarsal head hardware must be removed. The requested procedures are therefore reasonable and medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve left bunion correction, metatarsal osteotomy, and hardware removal for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided on September 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". We asked our coding 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 use of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation to validate that there was an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status during the initial 15 minutes of intraservice time, therefore, this service cannot be validated. We looked at this 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 the services (CPT 99152) provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in/roll-in shower (99998).You asked the Plan to pre-approve the shower. You say that the shower is medically necessary.The Plan denied your request. The Plan says the item is not a covered item.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.Therefore, we decided that the Plan does not have to pre-approve a walk-in/roll-in shower (99998).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal scaling and root planing provided on December 6, 2019.
You asked the Plan to pay more for the periodontal scaling and root planing. You say that the Evidence of Coverage states there is $0 coinsurance for a deep cleaning. You say the 30% coinsurance is an error. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 Plan is only obligated to pay 70% of the allowed amount for the periodontal scaling and root planing. Therefore, we decided that the Plan does not have to pay more for the periodontal scaling and root planing provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve Keytruda injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no support for covering this medication in this clinical scenario.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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee has an advanced renal cell carcinoma. Keytruda is FDA-approved for the treatment of advanced renal cell carcinoma as a single agent. It is a standard of care. The service is 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 injection have been met.Therefore, we decided that the Plan has to pre-approve Keytruda injection 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora cystourethroscopy provided on December 18, 2019.You asked the Plan to waive the copayment forthe cystourethroscopy. You say that you could only have the procedure done at the hospital that day. You say you should only be responsible for a $30 copayment like the cystoscopy you had in November. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules saya plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for an outpatient hospital facility.You have been asked to pay a $325 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the procedure was provided at an outpatient hospital.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe cystourethroscopy provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom breast prosthesis (L8035).
You asked the Plan to pre-approve custom breast prosthesis. You say that you are appealing the denial of the custom breast prosthesis because it is lighter than the standard prosthesis and you have not received a new prosthesis this year of any kind. The Plan denied your request. The Plan says this item is not covered by Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Records also show that a standard breast prosthesis was provided to you on January 10, 2020. Based on this information, we decided that Medicare rules for coverage of custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve custom breast prosthesis (L8035).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the services can be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bunionectomy.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of a trial and failure of conservative treatment.
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 pre-approve the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found Medicare guidelines advise that Medicare will authorized treatment to improve the functioning of a malformed body member. In this particular case, it is well documented that you have hallux abductovalgus deformity with pain to the medial aspect of the first metatarsal head left side. Palpation to the area reveals hardware which was placed during your first bunion surgery. Unfortunately, you have had recurrence of your first bunion. You are in pain and have failed treatments with topical anti-inflammatory medications. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve bunionectomy.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has a long standing history of diabetes for many years, along with peripheral neuropathy and gait disorder related to it. The Plan denied your request. The Plan says there is no evidence of insulin treatment.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found this monitor will not be used in place of a blood glucose monitor, as the enrollee is not on insulin treatment. Based on the medical records provided the continuous glucose monitor is not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attends bladder control pads, moisturizing lotion with aloe, digital thermometer.
You asked the Plan to pre-approve the over-the-counter items. You say that you feel that this should be covered and do not understand why this is being denied. The Plan denied your request. The Plan says the enrollee has already placed the maximum allowed orders for this benefit period.
The Plan must follow Medicare rules. Medicare generally does not cover over-the-counter items. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan covers up to $30 quarterly allowance for over-the-counter items. Therefore, we decided that the Plan does not have to pre-approve attends bladder control pads, moisturizing lotion with aloe, digital thermometer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device.
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).You asked the Plan to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device. You say that these services would be the best, minimally invasive treatment for the enrollee.The Plan denied your request. The Plan says this is experimental.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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found device in question is experimental. It is not covered under Medicare rules.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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit when provided by an OON provider.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 drug testing provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that your fingers are so callused that the lancet cannot penetrate your finger. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been 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 pre-approve a CGM and supplies. Our reviewer says that a CGM and supplies are not medically reasonable and necessary in this case. You are noted to be a non-compliant Type II diabetic, who takes both oral medications and set-dose, long-acting insulin. How often you check your blood glucose is not documented. There is no evidence that you use the results of blood glucose
monitoring to self-adjust, self-administered insulin, multiple times a day. Our physician reviewer found that your condition does not meet Medicare criteria for these items. 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 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.