Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for dental services (D0120, D4910).

You asked the Plan to pay in full for the dental services. You say that the service should be covered. The outstanding balance of $108.50 was erroneously billed. The Plan denied your request. The Plan says the outstanding amount is the amount that exceeds the $1,100 annual limit.

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 benefit was exhausted at the time the services were rendered. Therefore, we decided that the Plan does not have to pay in full for dental services (D0120, D4910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection (E2311) for a power wheelchair for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the electrical connection between the wheelchair controller and two or more motors (E2311) cannot be covered.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2311 is not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has sufficient strength and functional ability in the upper extremities that they will be able to control any power options through their own individual switches.

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 pre-approve an electrical connection (E2311) for a power wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (55866).

You asked the Plan to pay for the surgical services. You say that the service should be paid in full. The Plan
denied your request. The Plan says they have paid the amount required.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for outpatient surgery.

You have been asked to pay a 20% coinsurance for the surgical services. The surgical services fall within the
outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to pay for surgical services (55866).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xgeva 120MG/1.7ML vial (CPT Code J0897).

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says that they did not see certain details about the enrollee's use and treatment. The Plan states they may consider approval of this drug when used in a certain situation (when there is castration resistant or recurrent prostate cancer; and when the requested drug is being used for prevention of skeletal-related events). The Plan states they did not see information that shows this applies to the enrollee.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 medication. Our physician reviewer found Xgeva is FDA-approved for bone mets from solid tumors such as in this case. 

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 medication have been met. Therefore, we decided that the Plan has to pre-approve Xgeva 120MG/1.7ML vial (CPT Code J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from March 25, 2020 to June 10, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from March 25, 2020 to June 10, 2020.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical shoulder decompression (29826).

You asked the Plan to pre-approve a surgical shoulder decompression. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been shown to improve outcomes.

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 a surgical shoulder decompression. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found more conservative measures are needed to treat the enrollee's shoulder pain. There is no documentation of a recent 6 to 12-week trial and failure of physical therapy. There are no indications for shoulder 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 a surgical shoulder decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical shoulder decompression (29826).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hepatectomy (47120) provided on July 15, 2020.

You asked the Plan to pay for the hepatectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 47120 is hepatectomy, resection of liver; partial lobectomy. 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the hepatectomy. Our reviewer says that CPT code 47120 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a Hepatectomy, resection of liver; partial lobectomy was performed on July 17, 2020, therefore, this service cannot be verified. 

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 hepatectomy have not been met. Therefore, we decided that the Plan does not have to pay for the hepatectomy (47120) provided on July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 21, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 55650 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 55650 is vesiculectomy, any approach. 

We find that CPT code 55650 is not supported in the medical record. Specifically, there is no documentation of a vesiculectomy. 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 pay for the surgical services rendered on July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee needs this medication due to having heart failure. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Entresto for the enrollee.

Benefits for this drug 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (CPT Code 52442).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that the services are not 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 the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that you have symptomatic bladder outlet obstruction that has not responded to medical therapy and are an appropriate candidate for the Urolift procedure. Urolift is often used in patients with obstruction who also have prostate cancer and the implants may be used as fiducial markers if radiation treatment is required. 

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 been met. Therefore, we decided that the Plan has to pre-approve cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (CPT Code 52442).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system (CPT Code E2300).

You asked the Plan to pre-approve the power seat elevation system. You say that you are requesting review of
denial of services. The Plan denied your request. The Plan says the power seat elevation system is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

Medicare guidance says that a seat lift does not serve a medical purpose and cannot be covered. 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 power seat elevation system (CPT Code E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device. 
 
You asked the Plan to pre-approve an interspinous and/or interlaminar device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 an interspinous and/or interlaminar 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while published data indicate that the use of interspinous 
spacers with or without decompression for the treatment of lumbar spinal stenosis is not less effective than 
stand-alone decompression, high failure rates have been published. The medical literature has not shown better 
results with such devices. Stabilization devices may be considered when there is spinal segment instability. 
Segmental instability has not been demonstrated in this case. The effectiveness and safety of ISP is considered 
investigational at this time, and additional study is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an interspinous and/or interlaminar device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on August 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for pain management services. You say that you do not believe prior authorization was needed. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.

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 pain management services provided on August 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve F1Heme testing.

You asked the Plan to pre-approve the F1Heme testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that this testing has not been billed correctly.

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 the F1Heme testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this member presented with pancytopenia and molecular testing was sent along with the bone marrow biopsy. This is now standard given the wide differential of possible diagnoses.

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 F1Heme testing have been met. Therefore, we decided that the Plan has to pre-approve F1Heme testing.

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 the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the out-of-network services. You say that you would like reconsideration because you have been seeing this provider for 14 years and do not want to start over. The Plan denied your request. The Plan says there are in-network providers available who can render this service.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, a special kind of picture of your chest to screen for lung cancer, without contrast (dye) (CPT Code 71271).

You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. The reason this request cannot be approved is because: 1. Imaging may be supported if the enrollee has a 30 pack year smoking history (number of packs smoked per day times the number of years the enrollee smoked). The enrollee's records do not show that this applies to them. 2. Imaging may be supported if the enrollee is a smoker or quit within the last 15 years. The enrollee's records do not show that this applies to them. Therefore, we decided that the Plan does not have to pre-approve CT, a special kind of picture of your chest to screen for lung cancer, without contrast (dye) (CPT Code 71271).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.