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

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the item is 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 foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidoderm.

You asked the Plan to pre-approve Lidoderm. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Lidoderm.

Benefits for Lidoderm 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the enrollee needs continued care for a safe and seamless transition in care. The Plan denied your request. The Plan says the enrollee has reached her maximal level of function.

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.

Continued SNF services were requested. 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 physician reviewer found that the enrollee no longer qualifies for SNF coverage. There are no documented skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4).

You asked the Plan to pre-approve the dental services. You say that you believe it is necessary for the enrollee to receive these dental services. The Plan denied your request. The Plan says periodontal scaling and root planing 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, periodontal scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of supportive documentation of failed conservative measures.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is not enough documentation of conservative measures for spine pain. More conservative measures are needed. There are no red flags for laminectomy surgery 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.
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 proton beam therapy 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 medically necessary. Our physician reviewer found the generally accepted standard of care for
prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees;
however, the records show that the enrollee has consented to a clinical trial. This study is a prospective
comparison (between IMRT and proton therapy) of quality of life, toxicity, and disease control between
parallel cohorts of men with prostate cancer. It is not randomized between proton therapy and IMRT, and the
physician chooses the treatment to offer. The criteria for coverage are met and the services are 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 preapprove
proton beam therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator.
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because the records do not show that the enrollee has an approved condition for this procedure.
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered for certain
specific 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 spinal cord stimulator. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested spinal cord stimulator. Our
physician reviewer found the enrollee does not have an evidence-based indication for a spinal cord stimulator
trial.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve implantation of a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional rental months for oxygen concentrator
(E1390).

You asked the Plan to pre-approve additional rental months for oxygen concentrator. You say that this service
is medically necessary for your condition. The Plan denied your request. The Plan says the benefit has been
exhausted at this time.

The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen
equipment after 36 months.

We looked at the file and Medicare rules. In this case, the Plan has demonstrated that they have paid for 36
months of oxygen equipment and the benefit has been exhausted according to Medicare rules. Based on this
information, we decided that Medicare rules for coverage of additional rental months for oxygen concentrator
have not been met. Therefore, we decided that the Plan does not have to pre-approve additional rental months
for oxygen concentrator (E1390).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low vision services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore,
we decided that the Plan does not have to pre-approve low vision services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve block injection.

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 submitted records show that you have a history of headaches. The use of occipital nerve block injections is considered experimental/investigational and not the standard of care for your condition. 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 an occipital nerve block injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223 x 2), and a therapeutic drug injection (D9610).
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says deep sedation is not listed as a covered service. The Plan says therapeutic drug injection is not listed as a covered service either.
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 deep sedation and therapeutic drug injection are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223 x 2), and a therapeutic drug injection (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6010, CPT 21248).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services (D6010, CPT 21248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe insert (L3010).

You asked the Plan to pre-approve shoe insert. You say that the item should be covered. 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 shoe insert (L3010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6241, D6751).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D6241, D6751).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out of network provider.

You asked the Plan to pre-approve the dialysis services with an out of network provider. You say that the enrollee wants to continue dialysis at the out of network facility. The Plan denied your request. The Plan says out of network care would not be medically necessary but they will approve 25 visits for transition to an in-network center.

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 services. Therefore, we decided that the Plan does not have to pre-approve the dialysis services to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says medical care is ongoing, and the amount of therapy is appropriate to meet the enrollee's needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methylenetetrahydrofolate reductase testing.

You asked the Plan to pre-approve MTHFR testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that testing for the MTHFR gene is not medically necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MTHFR testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Methylenetetrahydrofolate reductase testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex device. You say that insertion of the posterior spinous process device is considered medically reasonable and necessary when all criteria has been met. The Plan denied your request. The Plan says Vertiflex is investigational and experimental and the enrollee is not receiving this device as part of a Medicare covered clinical trial. Experimental and investigation procedures are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says that guidelines only support three PET scans.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the requested PET scan is medically necessary in this case. Our physician reviewer found this patient has largely had PET scans to assess disease and has diffuse disease in nodes and bones. She is on active therapy. The service is 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 a PET scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 testing provided to the enrollee on May 20, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says that Healthcare Common Procedure Coding System (HCPCS) code U0002 CR (1 unit) remains
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 U0002 is "2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID 19), any technique, multiple
types or subtypes (includes all targets), non-CDC."
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 testing. Our reviewer says that the
services at issue in this case were supported by the medical records. Our coding reviewer found per Medicare
Administrative Contractor (MACC) COVID-19 Test Pricing, January 25, 2021, a laboratory performing non-
CDC laboratory tests for SARS-Vov-2/2019 could bill using HCPC U0002.
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 testing have been met. Therefore, we decided that the Plan has to pay for
COVID-19 testing provided to the enrollee on May 20, 2020.