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

We decided that the Plan does not have to pre-approve wheelchair van transportation.

You asked the Plan to pre-approve wheelchair van transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says transport by wheelchair van is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve wheelchair van transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bone imagining (78315) provided on October 12, 2020.

You asked the Plan to waive the copayment for bone imagining. You say that you cannot afford this charge and have only paid $75 in the past. The Plan denied your request. The Plan says this processed correctly.

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 $100 copayment for nuclear medicine services. 

You have been asked to pay a $100 copayment for bone imagining, which is considered a nuclear medicine 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 bone imagining (78315) provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed lumbar radiculopathy. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. The Vertiflex device 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 a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rotator cuff repair surgery (29827).
You asked the Plan to pre-approve rotator cuff repair surgery (29827). You say that the requested rotator cuff repair is medically necessary. The Plan denied your request. The Plan says the requested rotator cuff repair 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 rotator cuff repair surgery (29827). Our reviewer says that the requested rotator cuff repair is not medically necessary. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures including physical therapy. She is noted to have had multiple cortisone injections. However, formal therapy trials and failures are not documented in recent documentation. Furthermore, imaging studies do not support a massive and/or large, full-thickness cuff tear for which a (one of the proposed surgical procedures) rotator cuff implant might be a consideration. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right shoulder rotator cuff repair is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of rotator cuff repair surgery (29827) have not been met. Therefore, we decided that the Plan does not have to pre-approve rotator cuff repair surgery (29827).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this transport. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on January 14, 2021.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 diagnostic radiology services. You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 waive the copayment for myocardial perfusion imaging provided on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress (93018, 93016) provided January 25, 2021.
You asked the Plan to waive the copayment for the cardiovascular stress test. You say that you should not be responsible for a separate copay of $30 and the medication drug charge should not apply because it was not used for the test. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied correctly per the Evidence of Coverage.
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 $30 copay for each outpatient x-ray, diagnostic procedure and test. You have been asked to pay $30 copay for the cardiovascular stress test. The cardiovascular stress test falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 waive the copayment for cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress (93018, 93016) provided January 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.

You asked the Plan to pre-approve a CardioMEMS device. The Plan denied your request. The Plan says that this is not medically 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 a CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the CardioMEMS pulmonary pressure sensing device has been shown to decrease symptoms, improve heart failure class, and decrease re-hospitalization in patients who remain significantly symptomatic despite aggressive follow-up and clinical management. Given the trajectory of this enrollee, with his increasingly symptomatic congestive heart failure, and the recent recurrent admissions within the last year, CardioMEMS device implantation is medically indicated. It has published data, FDA indications, expert opinion and economic arguments to support its use as medically necessary in this specific type of clinical situation.

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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.

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 Vertiflex device (22869, 22870).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is a Medicare-covered procedure. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show this device is 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 the insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265).

You asked the Plan to pre-approve total electric hospital bed. You say that this item is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 13, 2020.

You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges because the laboratory services were part of your annual wellness exam. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $10 copayment for laboratory tests. 

You received laboratory services on November 13, 2020. Laboratory services are not included in annual wellness exams and are subject to cost-sharing charges. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 waive the copayment for laboratory services provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel.
You asked the Plan to pre-approve Enbrel. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Enbrel.
Benefits for Enbrel 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of epoetin alfa (Epogen).

You asked the Plan to pre-approve epoetin alfa. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not meet the criteria.

The Plan follows Medicare rules. Medicare rules state that epoetin alfa such as Epogen may be covered under certain off-label indications in addition to FDA-approved label indications. 

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 epoetin alfa. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of epoetin alfa. Our physician reviewer found patients are commonly treated with Epogen on protocol with hematocrit over 30. The hematocrit under 30 is typically a chronic kidney disease criterion. Most end-stage renal disease patients have dosage adjusted and cut when necessary and held with hematocrit is over 34. Typically the Epogen is not stopped, but dosage adjusted as is being done for this enrollee. The enrollee is receiving common practice standard of care therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epoetin alfa have been met. Therefore, we decided that the Plan has to pre-approve use of epoetin alfa (Epogen).

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78815).
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not had other testing that strongly suggests a cancer diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the requested PET scan is medically reasonable and necessary. Our physician reviewer found although you have a smaller nodular noted, you also have increased mediastinal lymph nodes including a paratracheal lymph node that increased from 1.4 cm on a computed tomography (CT) scan in October of 2020 to 2 cm on most recent CT scan in February. A PET scan would evaluate likelihood of malignancy in the nodular consolidation and nodes and guide treatment decision in terms of best site to biopsy. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78815).
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 parathyroid adenoma surgery to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve parathyroid adenoma surgery. The Plan denied your request. The Plan says the provider is non-participating with this member's closed provider system. There are participating providers that can provide the requested services within the member's provider system.

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 parathyroid adenoma surgery to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical boot.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a surgical boot.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).

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 a TTE is covered when specific criteria are 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 services are not medically necessary. Our physician reviewer found the submitted records contain only a single telehealth visit. There is reported sudden onset of an upper respiratory infection-type symptoms associated with intermittent shortness of breath. You have no prior history of coronary artery disease, congestive heart failure, or any other cardiovascular disease. Based on the records, there is no clinical indication to support the TTE at this time. The services are 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 transthoracic echocardiogram (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary for the enrollee. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.