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

We decided that the Plan does not have to pay for a drug test provided by an OON provider.

You asked the Plan to pay for a drug test. You say that you have to see all these providers at the same time.
You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior
authorization was not obtained by a participating provider.

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 a drug test provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow injections.

You asked the Plan to pre-approve Fluid Flow injections. You say that the service is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the use of the product(s) is helpful for treatment of your health problem.

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 Fluid Flow injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not support that the Fluid Flow injections safe and effective. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow injections have not been met. Specifically, there is no documentation indicating this service is safe and effective for your diagnosis. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow injections.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve transcatheter aortic valve repair (TAVR) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that the records do not demonstrate that the patient is
symptomatic.

The Plan must follow Medicare rules. Medicare rules say that TAVR is covered if the above criteria have been
met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. The enrollee has severe
aortic stenosis and some mild decrease noted in his left ventricular ejection fraction (LVEF) based on
echocardiographic criteria. Though more subtle, there is reported increasing activity limitation due to fatigue,
which is the first sign of symptomatic aortic stenosis before more severe and debilitating symptoms start. His
aortic velocity is high consistent with severe aortic stenosis and he has had a thorough guideline directed
evaluation by a multi-disciplinary heart team who have recommend TAVR. The clinical symptoms, objective
findings and medical evaluation all meet FDA and CMS criteria for consideration of aortic valve replacement,
and he has been appropriately evaluated by the multidisciplinary heart team per CMS guidelines. Our physician
reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to preapprove
transcatheter aortic valve repair (TAVR) for the enrollee.

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 the insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for the enrollee's medical condition. The Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5.

FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis; which have not been adequately addressed in the medical records. There is no documentation of the enrollee's height, weight or body mass index. There is imaging evidence of scoliosis of the lumbar spine, with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network provider.
You asked the Plan to pre-approve an out of area, out of network, office visit. You say that you want to see a physician while living in another state, out of the area. The Plan denied your request. The Plan says this is not urgently needed care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered from September 3, 2019 to January 28, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that ESRD-related lab services must be billed with the -AY modifier for separate payment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required -AY modifier. 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 laboratory services rendered from September 3, 2019 to January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3910, D3950) 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 this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D3910, D3950) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
You asked the Plan to pre-approve BRCA testing. You say that the enrollee has a strong family history of cancer and a personal history of eccrine carcinoma of the skin. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the enrollee has no prior history or current diagnosis of a covered condition for this testing.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is considered non-covered screening. We looked at the file and Medicare rules. This testing is not being requested for a covered indication and is considered by Medicare to be non-covered screening. Based on this information, we decided that Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the right knee (64624).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that overall, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this procedure for the enrollee. Exceptional indications and or exceptional circumstances are not evident in this case. Therefore, the request for genicular nerve radiofrequency ablation (RFA), of the right knee, is not medically reasonable and 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the right knee (64624).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ubrelvy 100mg tablet medication.

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary. The Plan denied your request. The Plan says this medication is not a covered benefit under your contractual policy.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Ubrelvy 100mg tablet medication.

Benefits for this medication 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

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 the enrollee does not meet the criteria for LTACH 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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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. 

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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pupal debridement (D3221) and periapical x-ray (D0230) provided on November 11, 2020.
You asked the Plan to pay for the pupal debridement and periapical x-ray. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says that the claim processed correctly.
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 pupal debridement is not among those covered under this benefit. The file also confirms the Plan has already covered one periapical x-ray for this year. Therefore, we decided that the Plan does not have to pay for the pupal debridement (D3221) and periapical x-ray (D0230) provided on November 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0425, A0428) provided on May 18, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 copayment for Medicare-covered ambulance services. The cost sharing applies for each one-way trip. You have been asked to pay a $243.58 copayment for the one-way ambulance trip provided. This is the Plan allowable amount which is less than the applicable copayment for this service. 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 copayment for the ambulance transportation service (A0425, A0428) provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80050) provided on November 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that you had just relocated to a new area and could not go to a network provider. The Plan denied your request. The Plan says this service was not authorized.
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 laboratory services (80050) provided on November 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator device.

You asked the Plan to pre-approve osteogenesis stimulator. You say that due to the enrollee's age and condition
he would benefit from early intervention with the osteogenesis stimulator. The Plan denied your request. The
Plan says the denial of authorization for use of this device is correct, because the enrollee does not meet the
Medicare criteria for an osteogenesis stimulator.

The Plan follows Medicare rules. Medicare rules state that an osteogenesis stimulator will be covered when
specific clinical criteria have been met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve osteogenesis stimulator. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested osteogenesis stimulator. Our
physician reviewer found it is well established in the medical notes that this osteogenesis bone stimulator is
being requested for a fresh 5th metatarsal fracture roughly 8 days old. Medicare guidelines advise that an
osteogenesis bone stimulator may be utilized for patients with a nonunion of a fracture documented by a
minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator,
separated by a minimum of 90 days. Use of ultrasonic osteogenesis stimulators for the treatment of a fresh
fracture or delayed union will be denied as not medically necessary. This particular patient does not have a
documented nonunion of the fracture to the fifth metatarsal base.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve an osteogenesis stimulator device.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Artacent WoundSkin Substitute Graft Procedure (CPT code(s): Q4169 and 15275), for the enrollee.
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 based on the documentation provided from February 18, 2021, it states the wound is healing well and there is healthy granulation tissue. The Plan states the documentation provided is abundantly clear that the enrollee's scalp wound is healing well, and they are responding to conventional wound care.
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 Artacent Wound Skin substitute is an allograft product that may be used as a wound covering in various surgical procedures including Mohs surgery and chronic wounds. In this case, the documentation indicates that at the last visit three weeks after the procedure, there is poor healing. The skull is exposed with minimal granulation tissue. Coverage of the wound is medically reasonable and necessary. Therefore, the requested 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 the services have been met. Therefore, we decided that the Plan has to pre-approve Artacent WoundSkin Substitute Graft Procedure (CPT code(s): Q4169 and 15275), for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical first x-ray (D0220) intraoral periapical each additional x-ray (D0230).

You asked the Plan to pay for the dental services. You say that the plan is using the wrong schedule of benefits. The Plan denied your request. The Plan says this service is not covered under the plan benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral periapical first x-ray (D0220) intraoral periapical each additional x-ray (D0230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered on
October 5, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any DMEPOS item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 knee orthosis with suspension sleeve rendered on October 5,
2020.