Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 11, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 physician's services. 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 physician's services provided on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab (J9022).

You asked the Plan to pre-approve Atezolizumab. The Plan denied your request. The Plan says this drug is not medically necessary for the enrollee.

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 Atezolizumab. Our reviewer says that Atezolizumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested treatment is supported for use in individuals with specific gene expression traits. Our reviewer found that the documentation does not include the gene expression of the enrollee's tumor. Without this documentation, 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 Atezolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab (J9022).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Asmanex.

You asked the Plan to pre-approve Asmanex. You say that Asmanex has worked for the enrollee in the past. The Plan denied your request. The Plan says this medication does not fall under Part B.

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 Asmanex.

Benefits for Asmanex 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-approve a low dose CT scan for lung cancer screening for the
enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the correct information was not received.

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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee's last CT of the chest dated 7/31/19 was NOT a low dose study but rather a diagnostic CT of the chest; CPT 71250 and followup for nodules should use the same diagnostic code. Since nodules are being followed a low dose CT would not be appropriate in any case. Also, the enrollee does not fulfill CMS criteria for low dose lung cancer screening. The requirement is a minimum of 30 pack years and she has a history of 10 pack years. Together with the abnormal findings on the exam of 7/31/19 a diagnostic CT, CPT71250 would be the exam of choice and not the low dose lung CT, G0297 as requested. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings to be provided by an OON provider.

You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says you are not a contracted provider with the enrollee's Plan. The Plan also says that services are only covered by the enrollee's Plan for in-network dentists.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings to be provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Original Medicare pays physicians, providers and suppliers for Medicare-covered services furnished to enrollees who have elected hospice. The Plan is responsible for non-hospice services that are not Medicare-covered, but that are offered as supplemental benefits under the Plan. You can find this rule in the Medicare Managed Care Manual, Chapter 8, Section 70.3.1. The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated. You can find this rule in the Medicare Claims Processing Manual, Chapter 11, Section 30.4.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) (87633) provided May 21, 2020.

You asked the Plan to pay for the molecular genetic screening testing. You say that there are no LCD or NCD policies that state this test is not covered or medically necessary. Please review and reprocess for further payment. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, the molecular genetic screening testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) (87633) provided May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedures (codes D4273 and D4283), non-autogenous connective tissue graft (D4275), and non-intravenous conscious sedation (D9248).
You asked the Plan to pre-approve the autogenous connective tissue graft procedures, non-autogenous connective tissue graft, and non-intravenous conscious sedation. You say that you were advised that you should have the autogenous tissue grafts. You also say that the long term effect of delaying this surgery is the possibility of the loss of teeth in those areas, and continued inflammation. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 autogenous connective tissue graft procedures (codes D4273 and D4283), non-autogenous connective tissue graft (D4275), and non-intravenous conscious sedation (D9248).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the enrollee has been treated with Fosomax, and you would like Prolia to be approved for the enrollee because it is the next best option. The Plan denied your request. The Plan says the enrollee has not had a trial with Zoledronic acid. The Plan also says that because the criteria have not been met, and it has not been demonstrated why it is medically necessary to make an exception for the enrollee, this request is not approved.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation does not support a history of an osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. Step therapy, as outlined by the Plan, requires this documentation. Our reviewer also found that without the support of the documentation, Prolia is not approved as step criteria is not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you are appealing. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 14, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the brain, abdomen, pelvis and chest for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information reviewed shows that the criteria for the requested scans was not 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a review of the PCP records reveals a history of non-Hodgkins lymphoma in the past, with chemotherapy. The stage, date of disease, etc are not illustrated. The enrollee last saw his hematologist in 2018. The last CT of the chest, abdomen, and pelvis was in 2018, which reportedly showed pulmonary nodules. No details or report of prior scans have been included. The size, nature and number of pulmonary nodules is not included to determine if these nodules need imaging followup. Physical exam has not revealed suspicion of recurrent lymphoma. In particular, the requested CT of the chest abdomen and pelvis if indicated would be more appropriate with contrast material unless there is a contraindication to same such as impaired renal function etc. Finally, a CT of the brain without contrast has been requested to rule out "reversible" causes of cognitive decline. No quantification of cognitive decline such as MMSE testing is in the records. The enrollee has had prior cardiac surgery, but it is unclear if there is contraindication to MRI if imaging, a more sensitive brain imaging tool, based upon neurocognitive testing, is indicated. Such a contraindication could be an implantable battery operated device such as pacemaker. In summary, the enrollee has an incompletely documented history of non Hodgkins lymphoma and non quantified cognitive impairment. Medical necessity of the requested scans has not been established in the records provided. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the brain, abdomen, pelvis and chest for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on July 27, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on July 27, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on July 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services with no transportation.

You asked the Plan to pay for ambulance services. You say that providing payment for these services is imperative to allow for continued services to patients. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services with no transportation
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 25, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on August 25, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that the enrollee needed this service because he could not have lifted himself off the floor after having major surgery. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 22, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not in hospice at the time of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on July 20, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 20, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a joint fusion procedure.

You asked the Plan to pre-approve Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). You say that this procedure is medically necessary and appropriate. The Plan denied your request. The Plan says sacroiliac joint fusion 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 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found sacroiliac joint fusion is experimental for the treatment of back pain. There is no documented instability, fracture, or lesion. sacroiliac joint fusion is not needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279) have not been met. Therefore, we decided that the Plan does not have to pre-approve a joint fusion procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not call and request this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on July 9, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.

You asked the Plan to pre-approve Tadalafil. 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 Tadalafil.

Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.