Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #8.
You asked the Plan to pre-approve the crown. You say that the enrollee had an accident and the tooth required a maxillofacial surgery procedure, and as a result the tooth color turned black. You also say that you recommend a crown as treatment. The Plan denied your request. The Plan says placing a crown on tooth #8 in its current state is not recommended. The Plan also says that there is advanced periodontal disease and significant bone loss, and does not meet the Plan's coverage criteria.
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 crown 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found tooth #8 has had a prior post and crown, but the provided x-ray does not show any clear root canal filling material apical to the post. Our reviewer found that it looks as though there is some bone loss to the level of the post, and the possibility of a root fracture must be evaluated along with a proper retreatment of the root canal before any consideration could be made to replace the crown on #8. Our physician reviewer also found that as it stands, the long term prognosis of the tooth is poor dude to endodontic concerns with the very short fill (if any) and possible fracture.
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 the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #8.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care.You asked the Plan to pre-approve the chiropractic care. You say that the medical records support continuing chiropractic care.The Plan denied your request. The Plan says there is no expectation that spinal manipulation will result in significant improvement in pain from a rotator cuff tear in a reasonable and predictable period. The Plan says that maintenance spinal manipulation is not a covered benefit under the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropracticmaintenance care. 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 chiropractic care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the submitted chart notes reveal ongoing ache and pain complaints in the cervical spine, right shoulder, hips and/or upper back, with the same or similar objective findings of fixations in thecervical spine, such as C2, C3, C6, the thoracic spine, such as T3, T4 and T5, the lumbar spine, L3, L4 and L5 and the right sacroiliac joint. Treatment throughout care includes manipulation of the cervical spine (impulse), thoracic spine (diversified), lumbar spine (flexion-distraction technique) and pelvis (impulse), as well as axial traction. The submitted chart notes reveal no clinical improvement; with no evidence that further clinical improvement can reasonably be expected from continuous ongoing care. The chiropractic treatment is maintenance therapy and is not supported or allowed per Medicare guidelines. There are no submitted imaging studies to reveal evidence of a subluxation and the submitted chart notes reveal only fixations and do not reveal evidence of subluxation per Medicare guidelines.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 chiropractic care have not been met.Therefore, we decided that the Plan does not have to pre-approve chiropractic care.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The Plan denied your request. The Plan says that the requested Opdivo is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the requested Opdivo is medically necessary. Our physician reviewer found the use of Opdivo is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal as long as used in combination with ipilumumab. Nivolumab/ipilimumab is recommended for patients with metastatic NSCLC, regardless of PD-L1 levels or histology; negative test results for EGFR, ALK, ROS1, METex14 skipping, RET, or BRAF variants; and no contraindications to immunotherapy. The compendium or article that supports the use is from the NCCN Guidelines Version 6.2020 Non-Small Cell Lung Cancer. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 as a practical matter, this enrollee does not require the necessary services on a daily, inpatient basis. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99335) provided on February 5, 2020.You asked the Plan to pay fora domiciliary or rest home visit. You say that this was medically necessary.The Plan denied your request. The Plan says no medical records were submitted to show this service took place.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. No medical records were submitted. Without this information, it cannot be verified that the billed service took place. Based on this information, we decided that Medicare rules for coverage of a domiciliary or rest home visit have not been met.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit (99335) provided on February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica.
You asked the Plan to pre-approve Lyrica. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Lyrica.
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 the requested LTACH care is medically
reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not
considered medically reasonable and necessary in this case.
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 the enrollee is with complicated hospital stay with respiratory failure, renal failure
requiring hemodialysis, sepsis, need for PEG feeding and high flow O2.
The enrollee does not have any needs that would require LTACH except perhaps the need for high flow O2.
There is no clear need for stay to be more than 25 days and no specific services are needed otherwise.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided
January 13, 2020 to January 28, 2020.
You asked the Plan to pay for the mechanical traction therapy. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are
not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the mechanical traction therapy (97012) provided January 13, 2020 to
January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
You asked the Plan to pre-approve a non-invasive home ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 non-invasive home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found this is not medically necessary above established alternatives, such as a proper-fitting CPAP mask or other methods. As such, this is a convenience item and not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-invasive home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77066)
provided March 18, 2020.
You asked the Plan to waive the copayment for the mammogram. You say that the test should have been
considered a screening mammogram. The Plan denied your request. The Plan says the physician billed this
service as a diagnostic mammogram based on your medical history. The correct cost sharing was applied.
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 $35
copayment for Radiology services.
You have been asked to pay a $35 copayment for the mammogram. The mammogram falls within the
Radiology services 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 a diagnostic
mammogram (77066) provided March 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor.
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CGM's are covered when The enrollee has been performing frequent (four or more times a day) testing. We looked at the file and Medicare rules. The record does not show the enrollee is testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFosaprepitant and Palonosetron.You asked the Plan to pre-approvethe requested drugs. The Plan denied your request. The Plan says the drugs are not supported for the enrollee's chemotherapy regimen.The Plan must follow Medicare rules. The rules say that Medicaremay pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician reviewer found that the enrollee has bilateral breast cancer. The requested use of Fosaprepitant and Palonosetron is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journalWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approveFosaprepitant and Palonosetron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the pontic-porcelain fused metal (D6241) and the retainer crowns-porcelain fused metal (D6751x 2) provided on March 29, 2019.You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services provided are not a covered benefit under your contractual policy.Medicare generally does not cover dental services. The Plan follows Medicare rules. The services you are asking the Plan to issue reimbursement for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the pontic-porcelain fused metal (D6241) and the retainer crowns-porcelain fused metal (D6751 x 2) provided on March 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets.
You asked the Plan to pre-approve Synthroid. You say that the medication is medically necessary. The Plan
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Synthroid tablets.
Benefits for Synthroid 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the lumbar spine.You asked the Plan to pre-approveCT scan. You say that you have extreme pain, and do not think you should go for physical therapy when doctors do not know what is wrong.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this CT scan is not medically necessary.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 CT scan. Our reviewer says that you do not meet the Medicare criteria for the requested CT scan. Our physician reviewer found there are no clinical signs/symptoms or exam findings to warrant a Computed Tomography (CT) scan of the lumbar spine. You have no clinical indication for this CT scan as the neurological examination is normal. You have no evidence of radiculopathy.We looked at this physician's review,the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the lumbar spine.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 19, 2019.
You asked the Plan to pay for the ambulance transport from dialysis. You say that the transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport from dialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport from dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
services coded 95941 provided on February 20, 2019.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are not payable.
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 95941 is continuous intraoperative neurophysiology
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while
in the operating room, per hour (List separately in addition to code for primary procedure).
We find that CPT code 95941 is not supported in the medical record. Specifically, code 95941 has a status code
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the continuous intraoperative neurophysiology monitoring services have not been met. Therefore,
we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
services coded 95941 provided on February 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 4, 2019 through December 18, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this is not a durable medical equipment code and it was not delivered to the member's home. The Plan denied your request. The Plan says S codes are not payable by Original Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the medical record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 4, 2019 through December 18, 2019.