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

We decided that the Plan does not have to pre-approve the remaining dose of Botox 100 units/ml solution (J0585).
You asked the Plan to pre-approve the remaining dose of Botox. You say that the remaining dose of Botox is medically necessary. The Plan denied your request. The Plan says the remaining dose of Botox is not medically necessary.
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 remaining dose of Botox. Our reviewer says that the remaining dose of Botox is not medically necessary. Our physician reviewer found the enrollee is with significant lower urinary tract symptoms that have not responded to treatment with tamsulosin.
Urodynamics indicate a non-compliant bladder with capacity of 150 cc. The enrollee is not a candidate for anticholinergic medications due to renal failure and not a candidate for myrbetriq due to ureteral reflux. Request is for coverage of a second dose of Botox. The medical records provided do not indicate whether he has received the initial dose of Botox and what the outcome was. The use of Botulinum Toxin for the treatment of Neurogenic bladder and Urge incontinence should be given no
sooner than every 90 days. However, in this case, the medical records provided do not indicate whether he has received the initial dose of Botox and what the outcome was. The second dose is not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the remaining dose of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining dose of Botox 100 units/ml solution (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 20, 2019 to November 8, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided  from August 20, 2019 to November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 13, 2019 to November 1, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by from August 13, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (code D5110), complete
mandibular denture (code D5120), removal of residual tooth roots (code D7250) of tooth #9, and extractions
(code D7210) of tooth #'s 6, 7, and 23.
You asked the Plan to pre-approve the complete maxillary denture, complete mandibular denture, removal of
residual tooth roots of tooth #9, and extractions of tooth #'s 6, 7, and 23. You say that you are in terrible pain
and your entire mouth hurts. The Plan denied your request. The Plan says the frequency limitation for the
dentures has already been met and tooth #'s 6, 7, and 23 have already been extracted. The Plan also says that a
less severe extraction must be considered instead of the removal of residual tooth roots for tooth #9.
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 covers the removal
of residual tooth roots when the services are medically necessary and reasonable.
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 removal of residual tooth roots
(code D7250) of tooth #9. Our reviewer says that the removal of residual tooth roots is not medically
necessary. Our physician reviewer found the service requested for tooth #9 is a code reserved for the removal
of a root following a prior extraction procedure that has a remaining segment in the bone that must be cut to be
excised. Our reviewer found that tooth #9 is a tooth that has an existing crown and is otherwise intact,
indicating no prior attempted extraction or loss of coronal structure other than for crown preparation. Our
physician reviewer also found that the code D7250 for tooth #9 is incorrect and cannot be supported by the
record, and therefore there is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of complete maxillary denture, complete mandibular denture, removal of residual
tooth roots, and extractions of tooth #'s 6, 7, and 23 have not been met.
Though the Plan offers a dental benefit in excess of Medicare coverage, complete, immediate, and partial
dentures are limited to one per 5 calendar years. The record shows that you received a maxillary partial denture
(code D5213) and a mandibular partial denture (code D5214) on June 11, 2018 and your complete, immediate,
and partial dentures benefit is now exhausted. The Plan also confirmed that tooth #23 was extracted on April
12, 2018, and tooth #'s 6 and 7 were extracted on May 17, 2018.
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (code D5110),
complete mandibular denture (code D5120), removal of residual tooth roots (code D7250) of tooth #9, and
extractions (code D7210) of tooth #'s 6, 7, and 23.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says that coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the CT scan is medically necessary. Our physician reviewer found a CT scan is a useful imaging modality to evaluate the extent of esophageal varices, the entire portal system, and surrounding anatomic structures, both above and below the diaphragm. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650), the knee orthosis
(L1851) and suspension sleeve (L2397) provided by Prescription Connection on July 26, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension
sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan
says criteria for the orthoses have not been met.
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 noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
(L0650), the knee orthosis (L1851) and suspension sleeve (L2397) provided by Prescription Connection on
July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 19, 2019 to November 7, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 19, 2019 to November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that your health will be at risk if the plan does not approve the requested CGM. The Plan denied your request. The Plan says that the requested CGM is not medically necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 CGM. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the G6 is being used to help with the pump in place of a blood glucose monitor. Our physician reviewer found that it is medically reasonable to have a CGM that enables the pump to do the best possible job at controlling blood glucose. Hence, the enrollee should be granted the new G6 upgrade sooner than April, as it will likely improve his health and control his A1C of 9.9%. 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 CGM have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
You asked the Plan to pre-approve a Freestyle Libre CGM system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested CGM system.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Medicare rules also say that in order to be covered for a therapeutic CGM, the enrollee must be using a blood glucose monitor and perform frequent (four or more times a day) testing. The file shows that the enrollee only tests twice per day. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis (CPT Code 0308T) provided by an in-network provider, from April 3, 2019 through April 10, 2019.
You asked the Plan to waive the cost-share for the services. You say that you are requesting reimbursement of services rendered because the toric lenses were necessary in order to maintain your natural mono vision and to reduce the possibility of wearing glasses. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan has issued payment to the provider for the cost of conventional intraocular lenses as if you had received conventional intraocular lenses rather than toric intraocular lenses. The Plan is upholding the payment for the portion of the toric lenses in excess of the conventional lenses. You are responsible for the portion of the cost which is the difference between the conventional lenses and the toric lenses. Conventional intraocular lenses fall into the benefit category of prosthetic devices and related supplies. Your EOC clearly states, that you have 4% coinsurance for covered prosthetic devices. As of the processing of the reprocessed claim for the conventional intraocular lenses, you had been assessed $600.40 of your maximum out-of-pocket amount of $1500. Therefore, you are responsible for the 4% coinsurance assessed on the conventional intraocular lens amount. 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 waive the cost-share for insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis (CPT Code 0308T) provided by an in-network provider, from April 3, 2019 through April 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that federal guidelines support the use of the requested CT scan for the enrollee's condition. You say that the CT scan is justifiable because the enrollee is diagnosed with coronary artery disease and has been smoking one and a half packs per day for over 10 years. The Plan denied your request. The Plan says the requested CT scan is not medically necessary. The plan says that the enrollee's chest x-ray shows no acute cardiopulmonary disease and the enrollee's smoking history is not enough to prove the medical necessity for the requested procedure.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found an annual screening for lung cancer with computed tomography is recommended for adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The enrollee is noted to have a history of smoking one and half packs of cigarettes a day over the last 10 years. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 16, 2019.
You asked the Plan to pay for the physician's services. You The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized by the Plan before the services are provided.
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 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 physician's services provided on May 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on September 25, 2019 through September 26, 2019.
You asked the Plan to pay for the self-administered drugs. You say that you would like reimbursement for the self-administered drugs you received. The Plan denied your request. The Plan says the claim for this medication should be filed under your Part D benefits.
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 pay for self-administered drugs provided on September 25, 2019 through September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for a total knee replacement for the right knee (27447).
You asked the Plan to pre-approve for a total knee replacement. You say that your patient reports that he is ambulating with a crutch with giving away of the right knee. He has night pain and weakness in the knee. He will undoubtedly end up with a replacement, no matter the conservative measures attempted. Insurance may still require these conservative measures, however, the best these measures would do is just delay the time of surgery needed. The Plan denied your request. The Plan says the total knee replacement 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 for a total knee arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support radiographic evidence of advanced joint disease. There is no clearly documented 3-month trial of conservative therapy. There are no documented distinct structural abnormalities, and no failed previous joint replacement/arthroplasty necessitating revision. 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 total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve for a total knee replacement for the right knee (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from August 15, 2019 to November 3, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.."] The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from August 15, 2019 to November 3, 2019.