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

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 8, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (CPT code D0470) and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (CPT Code D7311).
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 the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your 2021 Dental Benefit Schedule as covered benefits; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (CPT code D0470) and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (CPT Code D7311).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androderm.
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 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 Androderm.
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: Favorable

We decided that the Plan has to pre-approve replacement of a cardiac pacemaker and leads (procedure code
33208).

You asked the Plan to pre-approve pacemaker replacement. You say that the enrollee's pacemaker is
malfunctioning. The Plan denied your request. The Plan says that the denial of authorization for this service is
correct, because the Plan already approved cardiac pacemaker removal/replacement code 33238, so this request
is a duplicate.

The Plan follows Medicare rules. Medicare rules state that cardiac pacemakers may be covered under certain
circumstances. 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 pacemaker replacement. Our reviewer
says that the requested cardiac pacemaker replacement procedure is medically necessary and reasonable for the
enrollee. Our physician reviewer found at issue is whether procedure code 33208 is a covered service for the
enrollee when the Plan has already approved procedure code 33238. Code 33238 involves replacement of the
cardiac pacemaker pulse generator, while code 33208 involves replacement of the pacemaker and the leads. In
this case, the enrollee requires replacement of the A lead. The battery generator is also going to be replaced.
Therefore, the elements for coverage of code 33208 are satisfied and this service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pacemaker replacement have been met. Therefore, we decided that the Plan has
to pre-approve replacement of a cardiac pacemaker and leads (procedure code 33208).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have spinal stenosis. The requested Superion spacer is experimental in nature, as more research is needed to show its safety and effectiveness. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the crown. We decided that the Plan does not have to pay for the core
build up and unspecified preventive service.
You asked the Plan to pay for the crown. You say that before every visit, you consult with the Office Manager
to inquire if you have enough benefits to get the services done. You say that now that the work has been done,
you have received bills for thousands of dollars. You also say that you cannot keep up with the dental work
which your medical condition impacts. The Plan denied your request. The Plan says coverage for a crown is
limited to 2 per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that
core build up is not listed as a covered service. The Plan also says that the unspecified preventive service is not
listed as covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The rules also say that
Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information
regarding its decision to deny coverage or payment.
We decided that the Plan has to pay for the crown.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that the Plan denied the crown that you received for tooth # 29 due to
frequency limitation. The Evidence of Coverage states that 2 crowns are covered per year. The provided
documentation shows that the Plan previously paid for a crown for tooth # 4 that you received on December 4,
2020. There is no documentation that the Plan paid for a second crown in 2020. Without documentation to
substantiate that the frequency limit has been exceeded, we cannot determine that the frequency limit has been
exceeded. Therefore, we decided that the Plan has to pay for the crown. The cost sharing amount still applies.
We also decided that the Plan does not have to pay for the core build up and unspecified preventive
service.
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 pay for the core
build up and unspecified preventive service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 17, 2020.
You asked the Plan to pay for the evaluation. The Plan denied your request. The Plan says that you had a comprehensive evaluation in November of 2020. A comprehensive evaluation will only be covered once every 3 plan years. At the time of service, your benefit for this evaluation type was exhausted and payment cannot be made.
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. The Plan can cover one comprehensive oral evaluation every 3 plan years. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services were provided in a frequency that exceeds what is allowed by the Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom finger prosthesis.

You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says the requested prosthesis cannot be covered, as the incorrect code was used.

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 prosthesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you are unable to participate in mobility-related activities of daily livng with a standard (non custom) prosthesis. This custom prosthesis appears to exceed your medical need. There are no physician medical progress notes indicating a medical need for this prosthesis. 

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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom finger prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that records show the enrollee no longer has an illness that is
complex enough to require further hospital care.
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. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that these items are necessary for the
enrollee's condition. The Plan denied your request. The Plan says these items are not covered because they are
considered convenience items primarily hygienic in nature.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary compressed oxygen tank.

You asked the Plan to pre-approve oxygen equipment. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this is being requested for preventive/precautionary purposes and is not considered a medical necessity.

The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

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 oxygen equipment. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested oxygen equipment. Our physician reviewer found the enrollee has a history of chronic obstructive pulmonary disease, post stroke with right hemiplegia. This request is for an H-type oxygen tank for preventive or precautionary purposes. The submitted medical records are insufficient to establish that the enrollee meets the coverage conditions for this oxygen equipment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve a stationary compressed oxygen tank.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 16, 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 codes 95955 and 51785 are 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 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique. The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). We find that CPT codes 51785 and 95955 are not supported in the medical record. Specifically, there is no documentation of needle electromyography studies to support code 51785. There is no documentation of EEG placement during surgery to the brain to support code 95955. 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 services rendered on October 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is no new acute medical condition.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Care needs at this point are custodial and, as a practical matter, can be provided at a lower level of 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Afirma genomic classifier oncology testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary before proceeding with surgery. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have multiple thyroid nodules, several of which have been aspiration biopsied. One of these nodules is suspicious for cancer. The requested Afirma testing is not medically necessary or reasonable to determine the next course of treatment

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Afirma genomic classifier oncology testing for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.
You asked the Plan to pre-approve the requested services. You say that the enrollee's tremors put her at a severe fall risk. The Plan denied your request. The Plan says the 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. Five home health physical therapy visits 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 the requested services. Our physician reviewer found that most recent therapy documentation indicates the enrollee is able to ambulate up to 75 feet without an assistive device and was independent with bed mobility and transfers. She was independent with a home exercise program. There is no indication that she had any recent medication changes or hospitalizations. There has not been a recent decline in function. She has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (atezolizumab) injections.
You asked the Plan to pre-approve the Tecentriq injections. You say that this treatment would likely be
effective for the enrollee's condition. The Plan denied your request. The Plan says the use of this treatment is
not supported by the Medicare-approved compendia.
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 Tecentriq injections. Our reviewer
says that the requested treatment is not considered medically reasonable and necessary. Our physician reviewer
found the requested drug is being used for the treatment of metastatic poorly differentiated high grade large cell
neuroendocrine carcinoma from the stomach. The approved Medicare compendia do not contain a positive
citation for the use of the requested drug for this indication. There is insufficient literature support for the
requested drug for the noted indication. The elements of the coverage criteria are not satisfied.
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 Tecentriq injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Tecentriq (atezolizumab) injections.