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

We decided that the Plan does not have to pre-approve MRI of a lower extremity (73718).
You asked the Plan to pre-approve the MRI. You say that the member has had a course of physical therapy and home exercise with no benefit. The Plan denied your request. The Plan says the clinical information received does not include sufficient evidence to support this service.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the request for MRI of the lower extremity is not medically reasonable and necessary. Our physician reviewer found there is no detailed physical exam of the left lower extremity documented and no evidence of pain on physical exam. There is no evidence that first line imaging with x-rays has been done and found to be non-diagnostic. Current evidence based medical literature and guidelines suggest that MRI performed without prior radiography is not the recommended standard 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of a lower extremity (73718).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the excision or destruction of an intranasal lesion (90117) provided on September 3, 2019.

You asked the Plan to pay for the excision or destruction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the operative report did not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 30117 is excision or destruction (eg, laser), intranasal lesion; internal approach.

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 excision or destruction. Our reviewer says that the enrollee presented for surgical intervention of Balloon Sinuplasty and submucous resection of the inferior turbinates bilaterally. Our physician reviewer found the operative report includes an addendum which now supports the use of CPT 30117.

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 excision or destruction have been met. Therefore, we decided that the Plan has to pay for the excision or destruction of an intranasal lesion (90117) provided on September 3, 2019. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitoring system.You asked the Plan to pre-approvea Dexcom G6 continuous glucose monitoring system. You say that you want to use a Dexcom G6 CGM.The Plan denied your request. The Plan says you are notinsulin treated.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. The records show you are not insulin treated by pump or injection. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 continuous glucose monitoring system have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult dentition (D8090) and orthodontic retention (D8680).
You asked the Plan to pre-approve the comprehensive orthodontic treatment and orthodontic retention. You say that this enrollee needs the orthodontic treatment due to premature contact causing fracture to mandibular anteriors. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.
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 comprehensive orthodontic treatment of the adult dentition (D8090) and orthodontic retention (D8680).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a tenotomy (28011) provided on October 10, 2019. You asked the Plan to pay for the tenotomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate that this service was performed. 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 28011 is tenotomy, percutaneous, toe; multiple tendons. 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 tenotomy. Our reviewer says that CPT code 28011 does not meet criteria for billing or reimbursement consideration. Our physician reviewer found the records indicate that one tendon in each toe was repaired. 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 tenotomy have not been met. Therefore, we decided that the Plan does not have to pay for a tenotomy (28011) provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9945).
You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says occlusal guard is not listed as a covered service.
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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thigh high compression stockings and a mastectomy sleeve.You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary.The Plan denied your request. The Plansaysthe necessary information was not provided to support the need for this request.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are non covered because they do not meet the statutory definition of a surgical dressing. Although these items may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve thigh high compression stockings and a mastectomy sleeve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you at the in network rate for the 2 additional surgical extractions (D7210) provided on August 13, 2019 by an out of network provider.
You asked the Plan to reimburse you at the in network rate for 2 additional surgical extractions. You say that the extractions were an emergency. You say that they were becoming abscessed. You say that you had been on antibiotics for 3 weeks and have a pacemaker. You also say that you were not able to find an in network dentist. The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan also says that the frequency limit has been exceeded.
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 and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 extractions that you received on August 13, 2019. Therefore, we decided that the Plan does not have to reimburse you at the in network rate for the 2 additional surgical extractions (D7210) provided on August 13, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a swim spa.
You asked the Plan to pre-approve a swim spa. You say that you need a swim spa because you are in a lot of pain and your doctor recommends aqua therapy. The Plan denied your request. The Plan says a swim spa is not considered by Medicare to be durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a swim spa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam tab 0.5 mg.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Lorazepam tab 0.5 mg.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay foranesthesia services received from March 8, 2019 to March 29, 2019.You asked the Planto pay forthe services. You say that you were not aware of any additional charges, and you were not told that they would apply.The Plandenied your request. The Plansaysthatthis is not a covered service.The Plan must follow Medicare rules. The rules 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.The Planhas not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not provided any of the medical records for any of the multiple claims at issue in this case. They have not substantiated their denial.Therefore, we decided that the Planhas to pay foranesthesia services received from March 8, 2019 to March 29, 2019.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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 a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral, an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) coronary calcification (EBCT) (75571).
You asked the Plan to pre-approve a CT coronary calcification (EBCT). You say that the service is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that 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 a CT coronary calcification (EBCT). Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no evidence that the enrollee is having cardiac signs or symptoms. The vascular calcifications seen on the recent CT chest are expected in a 69-year-old. The requested test will not change the enrollee's treatment. Therefore, the requested EBCT is not shown to be medically necessary or reasonable. 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 CT coronary calcification (EBCT) have not been met. Therefore, we decided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 18, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for assistance after the stroke. The Plan denied your request. The Plan says medical conditions are stable, and they do not require daily physician oversight.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFebuxostat for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is a Medicare plan with only Part B 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-approveFebuxostat for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided from November 2, 2018 to November 7, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the therapeutic exercises. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 has network providers available who can provide 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 therapeutic exercises (97110) provided from November 2, 2018 to November 7, 2018 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo injection for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this drug is helpful for treatment of malignant neoplasm of vulva.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee had metastatic disease progression following a lapse in treatment related to a different medical diagnosis. Review of compendia including NCCN guidelines do not support the use of Opdivo for the treatment of this enrollee's diagnosis. Without the support, medical necessity cannot be determined as the treatment plan is considered investigational. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvea consultation and a deep cleaning to be performed by an oral surgeon.You asked the Planto pre-approvethe services. You say that this is medically necessary for intermittent pain.The Plandenied your request. The Plansaysdental services are only covered when provided by a participating general dentist.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 services when the services are medically necessary and reasonable, and provided by a participating general dentist. These services are to be provided by an oral surgeon. This type of dental provider is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea consultation and a deep cleaning to be performed by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee had his toe amputated on March 9, 2020. You say that the enrollee is still at level 4 and needs to remain at the SNF until his levels are at a 1. You say that, with the COVID-19 spread, the administrator at the enrollee's assisted living facility does not want health care visitors coming to check in. The Plan denied your request. The Plan says the records show that the enrollee's recovery has reached a new functional baseline.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs and clear lungs. The enrollee was alert and oriented. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a stand-by assist level with functional mobility, including gait to 150 feet with a rolling walker. The enrollee varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.