Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the next generation sequencing (NGS) rendered to the enrollee on May 9, 2019.
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 that the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when 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 these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of overlapping sites of left bronchus and lung with secondary malignant neoplasm of other digestive organs. The enrollee has a diagnosis of recurrent metastatic adenocarcinoma of the left lung, the documentation does not suggest that this was repeat NGS testing for the same tumor, and further cancer treatment was planned. The testing was reasonable and 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 been met. Therefore, we decided that the Plan has to pay for the next generation sequencing (NGS) rendered to the enrollee on May 9, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045, 73630, and 74177) provided on August 10, 2019.
You asked the Plan to pay for radiology services. You say that this claim should be reprocessed. The Plan denied your request. The Plan says payment of this claim is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for radiology services (71045, 73630, and 74177) provided on August 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aubagio for the enrollee.
You asked the Plan to pre-approve Aubagio. You say that the enrollee has been stable and compliant on this medication. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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 Aubagio for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 28, 2019 to November 16, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 28, 2019 to November 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip replacement surgery.
You asked the Plan to pre-approve the hip replacement surgery. You say that you would like reconsideration as you are in pain. The Plan denied your request. The Plan says you have multiple risk factors for complications from surgery and you are receiving conservative treatments that have shown to be effective.
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 hip replacement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found your BMI is too high and you must lose weight in order to meet coverage criteria for the surgery. 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 hip replacement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hip replacement surgery.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a low dose computed tomography (CT) scan (LDCT) for lung cancer screening provided on July 12, 2019.  You asked the Plan to pay for the LDCT for lung cancer screening. You say that the service is medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for a LDCT for lung cancer screening to be covered, specific criteria must be 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 the LDCT for lung cancer screening. Our reviewer says that the service is medically necessary. Our physician reviewer found the radiologist is only responsible for interpreting the CT scan, which s/he did. A patient with lung nodules no longer requires diagnostic CTs, as argued by the plan, if the nodules have been shown to be stable over a period of time. In 2018, this enrollee's nodules were noted to be stable when compared to 2017. Patients with stable nodules should be followed via general screening guidelines. This enrollee has not been shown to be symptomatic. There is no documentation of cough, shortness of breath or abnormal chest x-ray immediately prior to the provision of the LDCT in question. The service 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 LDCT for lung cancer screening have been met. Therefore, we decided that the Plan has to pay for a low dose computed tomography (CT) scan (LDCT) for lung cancer screening provided on July 12, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve the Euflexxa. You say that the Euflexxa is medically necessary. The Plan denied your request. The Plan says the documentation and medical records do not support the medical necessity for a step therapy exception.
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 the Euflexxa. Our reviewer says that the provided medical records do not indicate that you have tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects. 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facility care.
You asked the Plan to pre-approve these services. You say that the care you received at this facility previously was better. The Plan denied your request. The Plan says that there are in network providers that can manage your care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve facility care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee's constipation has significantly affected her mental status. The Plan denied your request. The Plan says the enrollee is no longer posing serious risk of harm to herself, and is not out of touch with reality.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued care beyond January 17, 2020 was requested for the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that the enrollee was compliant with treatment and medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. Active treatment was not taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. This enrollee does not meet the criteria for continued acute inpatient mental health treatment as the she was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diagnostic casts (D0470 x 2).
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 casts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the diagnostic casts (D0470 x 2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted neurological or neuromuscular diagnostic procedure (95999) provided on October 11, 2018.
You asked the Plan to pay for the unlisted procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.
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 asked our coder 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 unlisted procedure. Our reviewer says that the unlisted procedure represents train of four testing. Our reviewer found according to CPT rules, train of four testing is included in other intraoperative neuromonitoring procedures and is not separately reportable. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pay for an unlisted neurological or neuromuscular diagnostic procedure (95999) provided on October 11, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it does not appear the enrollee could participate in an intensive therapy program.
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 physician reviewer found that your current level of function is independent for grooming, bathing, and lower body dressing, modified independent for upper body dressing, and standby to contact guard assist for transfers using a rolling walker. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF at this time. You continue to be hypervolemic, and are not medically stabilized to transfer to a rehabilitation program. You may benefit and participate in additional physical and occupational therapy, but you do not appear to be able to tolerate this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation.
You asked the Plan to pre-approve the consultation. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consultation.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crowns for tooth #'s 5 and 16, root canal for tooth #5, and prefabricated post and core for tooth #5.
You asked the Plan to pre-approve the crowns, root canal, and post and core. You say that you had a root canal and crown placed on tooth #16. You also say that the crown fell off and you are experiencing discomfort as a result. The Plan denied your request. The Plan says that these services are not covered because there are 8 points of teeth (4 top and 4 bottom) in biting contact.
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. The Plan covers the crowns, root canal, and post and core when the services are medically necessary and reasonable. 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 crowns, root canal, and post and core. Our reviewer says that these services are medically reasonable and necessary. Our physician reviewer found a root canal, post and core, and crown for tooth #5 and a crown for tooth #16 are reasonable and necessary to maintain your occlusal function and stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns, root canal, and post and core have been met. Therefore, we decided that the Plan has to pre-approve the crowns for tooth #'s 5 and 16, root canal for tooth #5, and prefabricated post and core for tooth #5.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvefive (5) treatments of EpiFix.You asked the Plan to pre-approvefive (5) treatments of EpiFix. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested 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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve five (5) treatments of EpiFix. Our reviewer says that the documentation supports that the requested five treatments of Epifix are medically reasonable and necessary. Our physician reviewer found you have a diagnosis of varicose veins of left lower extremity with ulcer of unspecified site. On November 8, 2019, the venous stasis ulcer on the left lower leg measured 5x2 cm, with a depth of 0 cm. EpiFix has been shown to significantly improve healing time in a randomized, controlled multicenter clinical trial, compared to standard wound care and compression. Therefore, you meet criteria for the requested services.Review of the file shows that the plan uses Local Coverage Determination, LCD L36690 to support their denial. However, this LCD is not valid for the enrollee's home state of Wisconsin. Therefore, we cannot use LCD L36690 to substantiate our decision.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) treatments of EpiFix have been met.Therefore, we decided that the Plan has to pre-approvefive (5) treatments of EpiFix.If thePlan 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. Thisdoes not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. The records show that the plan made several attempts to obtain the records. Without records, it cannot be determined that Medicare coverage criteria have been met. 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 provided to the enrollee by an out-of-network provider on July 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided on July 31, 2019 by an out of network provider.
You asked the Plan to pay for the home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 home visit services provided on July 31, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that the SNF admission would help the member's health and quality of life. The Plan denied your request. The Plan says SNF admission is not medically necessary as the member could now transition to home with home health care or another outpatient setting for skilled services.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet severity of illness or intensity of service criteria for 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.