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

We decided that the Plan does not have to pay for breast biopsy services provided to the enrollee on September 12, 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 codes remain 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 the denied codes is: CPT 19085: biopsy, breast, with placement of breast localization device, when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance CPT 19086: biopsy, breast, with placement of breast localization device, when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance CPT 77066: diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the denied codes do not meet criteria billing or reimbursement consideration because the medical records submitted do not validate any date of service, therefore, there is not concrete evidence theses services were performed on September 12, 2019. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for breast biopsy services provided to the enrollee on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the joint injection provided to the enrollee on October 30, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records do not support the billed charge.
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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services provided. Our reviewer says that the code at issue does not meet criteria for reimbursement consideration. The medical records provided do not include documentation of permanently recorded images to corroborate this service. Therefore the service cannot be validated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the joint injection provided to the enrollee on October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional home health visits (G0299 and G0300).
You asked the Plan to pre-approve 15 additional home health visits. You say that one visit a week is not
sufficient to take care of your wounds. The Plan denied your request. The Plan says while these services are
medically necessary, there is no physician order.
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 15 additional home health visits. Our
reviewer says that the requested visits are not medically necessary. Our physician reviewer found the medical
records records do not show that skilled nursing services are required to effectively provide treatment, care,
and/or services which are medically necessary for you beyond what was already approved by the health plan.
The plan approved 12 visits. The request for additional visits beyond what was approved can only be deemed
medically necessary with a physician follow up and evaluation of your condition and the ongoing need for
skilled nursing 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 15 additional home health visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 15 additional home health visits (G0299 and G0300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for the
prevention of ulcers. The Plan denied your request. The Plan says you do not have a qualifying wound or ulcer.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6549.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 10, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted did not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says ongoing needs can be met in a lower level of care, such as IRF or even SNF
if the enrollee's medical and therapy needs are not complex.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an ACH for endocarditis. The
enrollee is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One for the enrollee.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says that diagnostic imaging does not support osteoarthritis and prior conservative treatment is insufficient to support failure of conservative treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that that Gel-One is not medically reasonable and necessary for the enrollee in this case. The patient is symptomatic with pain in the knee of short 7-day duration but no documentation that it interfered with the activities of daily living or ambulation and prolonged standing, or pain interrupting sleep. Physical Exam did not show any crepitus or limitation of range of motion. The clinical diagnosis of osteoarthritis of the knee is not supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. The patient has tried but not failed at least three months of conservative therapy. No documentation that the patient has failed to respond to intra-articular corticosteroid injection therapy. There is no documentation to support that the Gel-One is safe and effective for the patient's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Gel-One. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
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 self-administered drugs are not covered.
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 Vyzulta.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided September 10, 2019.
You asked the Plan to pay for the orthoses. You say that the documentation provided shows that these services were medically necessary for this enrollee. The Plan denied your request. The Plan says this was an unsolicited telephone call, all information was provided over the phone, there was no actual physical exam and this enrollee is not eligible for telehealth services.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the natural colored filling provided on September 16, 2019.
You asked the Plan to pay for the dental service. You say that fillings should be covered under the dental
benefit. The Plan denied your request. The Plan says fillings are not 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 natural colored filling is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the natural
colored filling provided on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an assay of creatinine (82565) provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the assay of creatinine. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 assay of creatinine (82565) provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of the enrollee's health problem.
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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental and investigational, and is the subject of ongoing clinical trials. Therefore, it is deemed not medically reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
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 that you live alone and at this time you
cannot dress yourself. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF
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 medically necessary. Our physician reviewer found that from a nursing
perspective, you received oral medications. You had stable vital signs and you were treated for pain with effect.
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT)
evaluations. By the dates in question, you were at a stand by assist level with functional mobility including gait
to 75 feet with a hemi walker. You required varying assist with activities of daily living. You were non weight
bearing to your left upper extremity. You could negotiate stairs with contact guard assist. Our physician
reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not
required to safely and effectively provide medically necessary and reasonable treatment. There are no
identifiable skilled therapy service needs. Skilled nursing or skilled therapy services (or a combination of these
services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the you do not require
the necessary services on an inpatient basis in a skilled nursing facility setting. You do not meet severity of
illness or intensity of service criteria on 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 continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral Orthovisc injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that the enrollee would be a great candidate for these injections, given her severe osteoarthritis. The Plan denied your request. The Plan says the evidence is insufficient, conflicting or poor regarding use of this injection for osteoarthritis of the knee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found that this enrollee was diagnosed with severe knee osteoarthritis. However, this type of treatment (hyaluronic acid injections) has limited evidence to support its use with significant clinical efficacy not being demonstrated in the collective studies currently. Therefore, this request for Orthovisc will be considered not 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral Orthovisc injections for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the enrollee does
not meet step therapy criteria.
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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary for the enrollee in this case. The provided medical records do not
indicate that the enrollee has tried and failed Zoledronic acid. The provided medical records do not indicate that
Zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Our physician
reviewer found the enrollee's condition does not meet step therapy criteria for Prolia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg Syringe.
You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary. The Plan denied your request. The Plan says the Prolia has been approved under Part D. Coverage under Part B is not necessary.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. While Prolia is normally eligible for coverage under Part B when supplied by a physician, the record shows that in this case the Prolia is provided for self-administration by a retail pharmacy. Coverage has been approved under Part D. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg Syringe.