Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a KNFB reader.

You asked the Plan to pre-approve the item. You say that you are legally blind. The Plan denied your request. The Plan says this is not a covered benefit.

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 KNFB reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on April 30, 2020 by an out of
network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that the member's facility failed to obtain prior
authorization. You say that you would like this claim reprocessed and paid. The Plan denied your request. The
Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that
there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided on April 30, 2020 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.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a requirement for insulin shots to be taken multiple times per day, and that the doses are adjusted based on the blood glucose levels in order for this monitor to be covered. You are not taking insulin injections. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the K3 microprocessor Knee (Orion3) coded as L5828, L5845, L5845, L5856, L5848, L5986 and L5987.

You asked the Plan to pre-approve the K3 microprocessor Knee. You say that the enrollee meets the definition of medically necessary for an above knee prosthesis with microprocessor knee and a K3 foot. The Plan denied your request. The Plan says the requested advanced foot/knee and rotational unit exceeds the enrollee's needs.

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 K3 microprocessor Knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's nurse practitioner and therapist, while documenting that member has K3 potential, does not give any reason why a microprocessor knee is medically necessary for the enrollee. The notes do not show why a mechanical K3 knee cannot be used for the member's initial prosthesis. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage.

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 K3 microprocessor Knee have not been met. Therefore, we decided that the Plan does not have to pre-approve the K3 microprocessor Knee (Orion3) coded as L5828, L5845, L5845, L5856, L5848, L5986 and L5987.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have has lumbar spinal stenosis (narrowing of the spinal canal). The requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. The services are 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 a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5212).
You asked the Plan to pre-approve a lower partial denture. You say that you need the denture to eat, and you want the Plan to pay. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on November 23, 2020. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says progress notes 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 by the provider does not contain medical records. Without supporting progress notes and office notes, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is at a custodial or maintenance level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6242) and two retainer crowns (D6752 x2).

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 a pontic (D6242) and two retainer crowns (D6752 x2).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the OneTouch Verio test strips.

You asked the Plan to pre-approve the OneTouch Verio test strips. You say that you would like reconsideration because you require these test strips while you wait for the Plan approved strips. The Plan denied your request. The Plan says that the information submitted doesn't meet medical necessity guidelines for coverage.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as if during an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-day transition period during which the plan provides non-preferred DME brands furnished in the previous year. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OneTouch Verio test strips have been met. Specifically, the record indicates that you became eligible with the Plan is April 2021. This means that the Plan is responsible for providing a 90-day transition period during which they must provide non-preferred DME brands. Therefore, we decided that the Plan has to pre-approve the OneTouch Verio test strips.

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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (SPECT) for the enrollee.

You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says that there are no new, recurrent, or worsening symptoms.

The Plan must follow Medicare rules. The rules say that cardiovascular nuclear imaging is covered for certain
indications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the isk profile for cardiovascular disease is significantly elevated with a 10-year risk of clinically
significant CAD of 14%.

He has symptoms of dyspnea on exertion and although some of this may be due to COPD, a cardiac origin of the symptoms, given his elevated risk profile, is certainly a reasonable possibility as described in the thorough and careful evaluation done by cardiology. As the enrollee has a possible anginal equivalent and his known lung disease limits his exercise capacity to obtain a diagnostic test using exercise alone, a chemical imaging stress study is indicated. Therefore, a Lexiscan SPECT nuclear stress study is medically necessary and reasonable for this clinical situation, and also meets the CMS rules for the use of this technology. 

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 imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (SPECT) 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636).
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee had excellent pain relief in the past with radiofrequency ablation. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale. We looked at the file and Medicare rules. The record indicates that the requested radiofrequency ablation is a repeat procedure, but the record does not indicate when the previous procedure was performed. Without this information, it cannot be verified that the enrollee had a minimum of consistent 50% improvement in pain for at least six months. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120),
bitewing radiographic images (D0272), intraoral periapical radiographic images (D0220), and protective
restoration (D2940) provided on November 17, 2020.

You asked the Plan to pay an additional amount for a periodic oral evaluation, bitewing radiographic images,
intraoral periapical radiographic images, and protective restoration. You say that you want the Plan to pay for
these services. The Plan denied your request. The Plan says the claims for a periodic oral evaluation and
bitewing radiographic images were processed correctly with the applicable out-of-network allowable amount
paid. Intraoral periapical radiographic images, and protective restoration are not covered benefits.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, bitewing radiographic images, intraoral periapical radiographic images,
and protective restoration have not been met. Specifically, the allowed amount of a periodic oral evaluation and
bitewing radiographic images for an out-of-network provider were paid by the plan. Any amount beyond the
allowed amount is your contractual responsibility. Additionally, intraoral periapical radiographic images, and
protective restoration are not covered benefits. Therefore, we decided that the Plan does not have to pay an
additional amount for a periodic oral evaluation (D0120), bitewing radiographic images (D0272), intraoral
periapical radiographic images (D0220), and protective restoration (D2940) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report for slides prepared elsewhere
(88321) provided on February 14, 2021.
You asked the Plan to pay for the consultation and report for slides. You say that you would like
reconsideration because the services were for a second opinion and the claim was billed correctly. The Plan
denied your request. The Plan says the member was in an inpatient stay on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 88321 is not supported in the record. Specifically, the record indicates that the member
was registered inpatient on the billed date of service so the claim must be billed with an inpatient place of
service code. Based on this information, we decided that Medicare rules for coverage of the consultation and
report for slides have not been met. Therefore, we decided that the Plan does not have to pay for the
consultation and report for slides prepared elsewhere (88321) provided on February 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair seat cushion (E2619) and back rest (K0108).
You asked the Plan to pre-approve the wheelchair seat cushion and back rest. You say that you would like this denial reconsidered for approval. The Plan denied your request. The Plan says these items are not considered to be primarily medical in nature and as such are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 the wheelchair seat cushion (E2619) and back rest (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that conservative therapy has not been effective, and this is minimally invasive. 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 a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective. 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic therapy (D3330) to be performed by an endodontist.
You asked the Plan to pre-approve the endodontic therapy. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an endodontist are 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy (D3330) to be performed by an endodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prevalon offload boots.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 Prevalon offload boots.