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

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveVertiflex. You say that Vertiflex would provide significant clinical and quality of life benefits for the enrollee while minimizing complications and risk.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is a lack of evidence to support that Vertiflex is as safe and effective as the gold standard of decompression.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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show its safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz Injections (J7321).You asked the Plan to pre-approveSupartz. You say that the injections are medically necessary.The Plandenied your request. The Plan says rules for coverage of Supartz have not been met.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 Supartz. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the enrollee has not had a trial of Physical Therapy or other Physical medicine modalities. Injections cannot be approved until other treatment measures have been trialed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz Injections (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Injection, gadolinium-based magnetic resonance contrast agent with CPT code A9579 provided on June 2, 2020.
You asked the Plan to pay for CPT code A9579. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 A9579 is Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml. We find that CPT code A9579 is not supported in the medical record. Specifically, there is another code Medicare uses for the services provided and billed using A9579. Based on this information, we decided that Medicare rules for coverage of CPT code A9579 have not been met. Therefore, we decided that the Plan does not have to pay for the Injection, gadolinium-based magnetic resonance contrast agent with CPT code A9579 provided on June 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services providedon April 3, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dateof service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveplatelet rich plasma (PRP) injections.You asked the Plan to pre-approvethe injections. You say that the enrollee has bilateral shoulder dysfunction due to tendinopathy of multiple tendons coupled with osteoarthritis of the glenohumeral joints. You say that the enrollee was able to undergo a brief course of platelet-rich plasma injection therapy for one of his shoulders with excellent results. You also say that it is undesirable that he would have to undergo a surgical approach for his shoulders which would result in incomplete recovery of the shoulder function necessary for his specific occupation.The Plan denied your request. The Plan says the provided documentation does not support that this care is needed to treat your condition and does not meet the coverage criteria for the injection of plasma.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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not include recent imaging, a detailed physical examination, or documentation of conservative therapies trialed. The reviewer found that overall, routine use of platelet rich plasma (PRP) is not recommended for most musculoskeletal conditions. The reviewer found that without the support of the documentation or compendia, medical necessity cannot be determined.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 injections have not beenmet.Therefore, we decided that the Plan does not have to pre-approveplatelet rich plasma (PRP) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from June 3, 2020 to June 8, 2020.
You asked the Plan to pay for the services. You say that you are seeking what you are owed. The Plan denied your request. The Plan says this is not a covered benefit.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided to the enrollee from June 3, 2020 to June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forelectrical stimulation (G0283) and therapeutic exercise (97110) provided July 1, 2020 to July 2, 2020.You asked the Plan to pay forthe chiropractic services. You say that you have uploaded medical records for appeal.The Plandenied your request. The Plan says this service is not covered under the plan benefits.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 service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forelectrical stimulation (G0283) and therapeutic exercise (97110) provided July 1, 2020 to July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe comprehensive oral evaluation (D0150), intraoral X-rays (D0210), and topical application of fluoride (D1208).You asked the Plan to pre-approvethe comprehensive oral evaluation, intraoral X-rays, and topical application of fluoride. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee has exhausted benefits for the comprehensive oral exam and intraoral X-rays and the topical application of fluoride is not covered.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.We looked at the file and Medicare rules. In this case, the enrollee has already received these services in August 2020. Therefore, they have exhausted their benefits for intraoral X-rays and comprehensive oral evaluation. Based on this information, we decided that the Plan's rules for coverage of comprehensive oral evaluation and intraoral X-rays have not been met. Though the Plan offers a dental benefit in excess of Medicare coverage, the topical application of fluoride is not covered.Therefore, we decided that the Plan does not have to pre-approvethe comprehensive oral evaluation (D0150), intraoral X-rays (D0210), and topical application of fluoride (D1208).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 9, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forrevision of total knee arthroplasty, with or without allograft (27486) provided March 13, 2020You asked the Plan to pay forthe surgical procedure. You say that you are attaching the operative notes. Please reconsider as it is not possible for the PA claim to be paid and the actual surgeon claim denied.The Plan denied your request. The Plan says the records do 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 27486 is revision of total knee arthroplasty, with or without allograft.We find that CPT code 27486 is not supported in the medical record. Specifically, the operative report didnot include documentation of a revision of a total knee arthroplasty, with or without allograft, for 1 component. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met.Therefore, we decided that the Plan does not have to pay forrevision of total knee arthroplasty, with or without allograft (27486) provided March 13, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home blood pressure monitor.You asked the Plan to pre-approvea home blood pressure monitor. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says a home blood pressure monitor is not covered by Medicare or the Plan for non-ESRD patients.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis ofhypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriatein this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approvea home blood pressure monitor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee has tried and failed conservative treatments.The Plan denied your request. The Plan says the records shows the enrollee has not had a four week trial of a basic pump. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReblozyl(J0896).You asked the Plan to pre-approveReblozyl. You say that the medication 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 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 Reblozyl. Our reviewer says that the medication is not necessary. Our physician reviewer found this reviewer did not find any supporting citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met.Therefore, we decided that the Plan does not have to pre-approveReblozyl (J0896).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe neurology services to be provided by an out of network provider.You asked the Plan to pre-approvethe neurology services. You say that the out-of-network provider is the only one with high qualifications that can get you off some of your medications.The Plan denied your request. The Plan says your doctor did not send requested clinical supporting documentation and they have in-network neurologists.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 thatwould require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe neurology services to be provided by an out of network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea GeneSight Psychotropic Assay (81479).You asked the Plan to pre-approvethe GeneSight Psychotropic Assay. You say that the genetic testing is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that GeneSight psychotropic is covered when ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder. 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 GeneSight Psychotropic Assay. Our reviewer says that the requested genetic testing is not medically necessary. Our physician reviewer found the ordering physician must be board certified in psychiatry or neuropsychiatry. The record shows that in this case the ordering physician for this test is not boarded in psychiatry or neuropsychiatry.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 GeneSight Psychotropic Assay have not been met.Therefore, we decided that the Plan does not have to pre-approvea GeneSight Psychotropic Assay (81479).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan eye drops.
You asked the Plan to pre-approve Rocklatan (J3490). You say that you want the enrollee treated with this
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B
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 Rocklatan eye drops.
Benefits for Rocklatan (J3490) 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (00813) provided April 10, 2020.You asked the Plan to pay forthe anesthesia services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services 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.We find that CPT code 00813 is not supported in the medical record. Specifically, the record for the procedure does not list the correct date of service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay foranesthesia services (00813) provided April 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient consultation with CPT code 99254 provided on April 11, 2020.You asked the Plan to pay forCPT code 99254. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT code 99254 has a status code of "I" under the Medicare Physicians FeeSchedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forthe inpatient consultation with CPT code 99254 provided on April 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot inserts.You asked the Plan to pre-approvefoot inserts. You say that you have pain and torn ligaments.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.  The records do not show that you 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-approvefoot inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two periodontal scalings and root planings.
You asked the Plan to pre-approve the scalings and planings. You say that this service is an adequate treatment
for the enrollee. The Plan denied your request. The Plan says this service is not a covered benefit under the
enrollee's plan.
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 two
periodontal scalings and root planings.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe advance care planning services coded 99497 provided on June 21, 2020.You asked the Plan to pay forthe advance care planning services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted does not include the face to face time spent providing this service. Based on this information, we decided that Medicare rules for coverageof the advance care planning services have not been met.Therefore, we decided that the Plan does not have to pay forthe advance care planning services coded 99497 provided on June 21, 2020.