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

We decided that the Plan does not have to pre-approve implantation of a leadless pacemaker device.
You asked the Plan to pre-approve leadless pacemaker. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is not enrolled in a Medicare-approved clinical trial for a leadless pacemaker and therefore this device is not covered.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemaker devices are only covered in a Medicare-approved clinical study. Leadless pacemakers are non-covered outside of an approved study. We looked at the file and Medicare rules. The requested leadless pacemaker procedure is not covered by Medicare outside of an approved clinical study. Based on this information, we decided that Medicare rules for coverage of leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a leadless pacemaker device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint block injections.
You asked the Plan to pre-approve these services. You say that you are in pain and don't have time to do physical therapy. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet blocks are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic low back pain and disc disease. You have radicular pain and documented sacroiliac (SI) joint pain as pain generators. You have not had a recent trial of physical therapy or other conservative therapy. The requested services do not meet the criteria for coverage and are not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint block injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5256) purchased on July 10, 2019.
You asked the Plan to pay for the hearing aids. You say that according to your book your hearing aids should be covered. You were not aware that you had to go through Hearing Care Solutions. The Plan denied your request. The Plan says hearing aids purchased through and out of network provider is not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan says that coverage for hearing aids is limited to Hearing Care Solutions. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5256) purchased on July 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an occipital nerve block for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 occipital neuralgia. She had a prior occipital nerve block that provided 50 percent pain relief for three weeks. The requested repeat block is the standard of care and is 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 an occipital nerve block for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the coinsurance for the total knee replacement surgery provided from July 11, 2019 to July 19, 2019.
You asked the Plan to reduce the coinsurance for the total knee replacement. You say that you were never an outpatient. You say you were told you would owe $200 per night for the room. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Medicare rules say a total knee replacement is on the inpatient only list. The Plan says you must pay 20% coinsurance for the total knee replacement as an outpatient procedure. Based on the Plan contract, however, you cannot be asked to pay more than a $200 copayment per day for the total knee replacement. ($200 x 2 days = $400). The record shows the pre-operative service was included in the inpatient copayment.
Therefore, we decided that the Plan has to reduce the coinsurance for the total knee replacement surgery provided from July 11, 2019 to July 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20mg Xarelto Tablets.
You asked the Plan to pre-approve the Xarelto. You say that the Xarelto is medically necessary for treatment of
the member's condition. The Plan denied your request. The Plan says this medication does not fall under the
member's Medicare Part B benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 20mg Xarelto Tablets.
Benefits for the Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 21, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you have cancer and have gotten weak after
going through chemo treatment. You say that you need rehab so that you can get strong and be able to return
home. You say that you have not been properly medicated while in the SKN. The Plan denied your request.
The Plan says the enrollee does not require daily skilled therapy or daily skilled nursing care.
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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or
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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.
You asked the Plan to pre-approve these services. You say that the power scooter will give the enrollee more independence in the home. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left leg weakness, arm weakness, impaired gait after stroke on October 26, 2017. A mobility evaluation was done on November 18, 2019 and a manual wheelchair was recommended as the safest and most appropriate mobility device as the patient was able to access his apartment with the manual wheelchair. He is able to self-propel in a manual wheelchair. Based on the records, the enrollee does not meet the criteria for coverage of the requested power scooter. 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 power scooter for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 111 additional skilled nursing visits, 48 additional home health aide visits and 5 additional occupational therapy services.
You asked the Plan to pre-approve the home health services. You say that the additional services are medically necessary. The Plan denied your request. The Plan says the additional services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the member does not meet Medicare coverage criteria for the home health services. Our physician reviewer found on appeal a total of 37 skilled nursing visits and 16 HHA visits were approved. This should be adequate to continue wound care and assist with ADLs. The records do not show that skilled nursing services, HH aide services, and therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the member beyond the visits that were approved on appeal.
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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 111 additional skilled nursing visits, 48 additional home health aide visits and 5 additional occupational therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for metastases.
You asked the Plan to pre-approve the radiation therapy. You say that your cancer as returned and needs to be
treated. The Plan denied your request. The Plan says the type of treatment requested is not supported to treat
your condition.
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 radiation therapy. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found radiation to the lung will not help a disease in axilla.
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 radiation therapy have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiation therapy for metastases.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92002) provided on July 31, 2019 by the out of network provider.
You asked the Plan to pay for an eye exam. You say that you are filing an appeal for service on July 31, 2019, as you received a bill for $55 and you have also paid out of pocket $76, totaling $131. You were told by the office that they are participating and didn't need a referral. When you paid the $76 you were okay with that as you believed at the time of service that is what you owed. The Plan denied your request. The Plan says while you are a member of the Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. You are responsible for paying the full cost of services that aren't covered by the Plan, either because they are not Plan covered services, or they were obtained out-of-network and were not authorized.
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 an eye exam (92002) provided on July 31, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73502) provided to the enrollee on September 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code is not supported.
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 73502 is "Radiologic examination, hip, unilateral." We find that CPT code 73502 is not supported in the medical record. Specifically, the diagnosis code attached to this CPT code is mismatched to the procedure modifier on the claim line. 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 radiology services (CPT 73502) provided to the enrollee on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forprostate cancer screening provided to the enrollee on May 29, 2019.You asked the Planto pay forthe screening. You say that this should be paid for.The Plandenied your request. The Plansaysthis procedure code is not found under the list of CPT codes granted waived status under CLIA.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 definitionof HCPCS G0103 is:Prostate cancer screening; prostate specific antigen test (PSA), total 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 screening. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found it cannot be determined if the code was supported in the medical records, as no medical records were submitted. Additionally, it appears that the code is an invalid procedure code, as it was not granted waived status.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 screening have not been met.Therefore, we decided that the Plandoes not haveto pay forprostate cancer screening provided to the enrollee on May 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9500 provided from July 17, 2019 to July 24, 2019.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the services billed are not payable.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 definitionof code S9500 is Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits codedseparately), per diem.We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9500 provided from July 17, 2019 to July 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound (76642), a diagnostic mammogram (77066), and a diagnostic digital breast tomosynthesis (G0279) provided on July 11, 2019 by out of network provider.You asked the Plan to pay foran ultrasound, a diagnostic mammogram, and a diagnostic digital breast tomosynthesis. You say that you received a denial for this claim on July 30, 2019, notifying you that authorization was required but not obtainedto show proof of medical necessity for this claim to be reconsidered. You have attached the requested records for yourreview.The Plan denied your request. The Plan says the Medical Center is a non-network provider who does not workwith the member's health plan, and the member was referred by the physician, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health 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 carefrom 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 foran ultrasound (76642), a diagnostic mammogram (77066), and a diagnostic digital breast tomosynthesis (G0279) provided on July 11, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a single upright knee orthosis for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an orthosis 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee with pain in the right knee. A knee exam on December 4, 2019 showed no significant laxity. There is no documentation of a knee injury or recent surgery. The requested knee orthosis does not meet the criteria for coverage and is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a single upright knee orthosis for the enrollee.