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

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer. You say that oral medications will not replenish the enrollee's
iron stores. The Plan denied your request. The Plan says the documentation does not show an intolerance to
oral iron, or that the enrollee has low iron associated with chronic kidney disease.
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 Injectafer. Our physician reviewer
found that the enrollee has chronic kidney disease, normocytic anemia. Normal iron, iron saturation and
ferritin levels were found on laboratory testing. The provided medical records do not indicate that Injectafer is
safe and effective for the enrollee. There is no indication in the records that oral iron has been tried and failed
or would be contraindicated. The provided medical records do not indicate that Injectafer is medically
reasonable and necessary for the 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 Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve ferric carboxymaltose (Injectafer).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic radiographic image (CPT Code D0330) provided on August 23, 2019.You asked the Plan to pay for the dental services. You say that at the visit you were told that all services were verified as covered under your insurance policy.The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forpanoramic radiographic image (CPT Code D0330) provided on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on April 2, 2019.You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the filedoes not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on April 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 2, 2020.
You asked the Plan to pre-approve these services. You say that you can't get up or go to the bathroom without assistance. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on December 2, 2019. You received oral medications and had stable vital signs. You received physical and occupational therapy and need assistance with functional mobility, including walking eight feet with a rolling walker. You need varied assistance with activities of daily living. You have no skilled therapy needs. You have skilled nursing needs but do not require skilled nursing on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not allow payment for DME to facilities that function as a skilled nursing facility, even if the enrollee is not in the Medicare-certified portion of the facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the services is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Osteogen ultrasound stimulator (E0760).
You asked the Plan to pre-approve the Osteogen ultrasound stimulator. You say that due to lack of healing this device is medically necessary. The Plan denied your request. The Plan says this device is not medically necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve the Osteogen ultrasound stimulator (E0760).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted evaluation and management service (CPT Code 99499), reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial (CPT Code 21248) and modification of a prefabricated abutment may be necessary (CPT Code D6056) from an out-of-network provider.
You asked the Plan to pre-approve the dental services. You say that you would like the services to be covered under the medical plan. The Plan denied your request. The Plan says items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare or the Medicare Advantage health 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. The provider is not in-network and furthermore, these services are not covered. Therefore, we decided that the Plan does not have to pre-approve unlisted evaluation and management service (CPT Code 99499), reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial (CPT Code 21248) and modification of a prefabricated abutment may be necessary (CPT Code D6056) from an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from July 20, 2019 to July 27, 2019.You asked the Plan to pay for the services provided. You say that the plan is inconsistent with reasons to not pay for services.The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment.We find that CPT code S9328 is not supported. Specifically, Medicare uses another code for the reporting of, and payment for, these services.Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided from July 20, 2019 to July 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.You asked the Plan to pre-approve facet joint injections. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you have exceeded the covered limit of procedures for a 12 month period.The Plan follows Medicare rules. Medicare rules say that for coverage for facet joint injection procedures the enrollee's pain must be inadequately responsive to conservative care. No more than 2 thermal radiofrequency sessions will be covered in any rolling 12 month period.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 facet joint injections. Our reviewer says that you do not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the documentation submitted shows no significant facet disease on imaging, or indication that you have failed conservative treatment methods such as physical therapy or manual therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

You asked the Plan to pay for Decipher test. You say that this testing should be viewed as medically necessary based on its inclusion in the National Comprehensive Cancer Network (NCCN) guidelines and clinical validity of the test.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee has not undergone a Radical Prostatectomy (RP), prostate-specific antigen (PSA) is not at its lowest level, and there is no metastatic disease reported.The Plan follows Medicare rules. Medicare rules say that Decipher testing is only covered when the enrollee meets certain specific criteria.
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 Decipher test. Our reviewer says that this testing does not meet all of the Medicare criteria for coverage. Our physician reviewer found National Comprehensive Cancer Network (NCCN) guidelines do not recommend molecular testing in patients with low disease risk unless life expectancy is greater than 10 years.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Decipher test have not been met. Therefore, we decided that the Plan does not have to pay for Decipher prostate cancer classifier assay provided on July 24, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on June 26, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no documentation that the bladder cancer is considered high risk, and it is documented that there is bleeding of the bladder into the urine.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and guidelines from the National Comprehensive Cancer Network (NCCN Guidelines Version 2.2020 Bladder Cancer) the Cxbladder test is not indicated. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on June 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires aggressive therapy and close physician monitoring. The Plan denied your request. The Plan says there is no need for physician supervision, or intensive interdisciplinary therapy.
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 physician reviewer found that the enrollee's current level of function is independent with feeding, minimal assist for grooming, upper extremity dressing with minimal assist, bed mobility with minimal assist, and ambulation with minimal assist using a rolling walker. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but he does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 28, 2019.You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial as the physician provided the services in good faith.The Plan denied your request. The Plan has determined that the Explanation of Benefits (EOB) from the primary insurance carrier is needed to have this claim processed. Therefore, the claim will need to be submitted to the primary insurance carrier first and then an EOB must be generated from the primary insurance first prior to the plan processing payment for the services. The member is not being held liable for the denied charges.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested that you submit the claim to the primary care insurance. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe initial hospital care (99223) provided on July 28, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve vertebral augmentation of the L4/L5 vertebral bodies for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says that there are other causes of pain generation present on MRI imaging.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has acute or subacute lumbar vertebral body fractures. Heal so has degenerative disc changes at multiple levels as well as facet arthropathy and foraminal stenosis. A pain plan is clearly delineated on page 3 of the progress note of 9/20/19. Kyphoplasty was ordered and denied as there are other pain generators, but the health plan ignores the fact that he is not a candidate for corrective procedures which require general anesthesia. The enrollee meets the criteria for kyphoplasty. It is medically reasonable and 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 the surgery have been met.Therefore, we decided that the Plan has to pre-approve vertebral augmentation of the L4/L5 vertebral bodies for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency air transportation (A0140) provided on July 19, 2018.
You asked the Plan to pay for non-emergency air transportation. You say that the services were necessary since you had to be transported on a stretcher during your return flight home. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 non-emergency air transportation. Our reviewer says that the services were not medically necessary. Our physician reviewer found the documentation shows you were stable after treatment in the hospital out of the country for a stroke. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency air transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency air transportation (A0140) provided on July 19, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046), computed tomography (CT) scan of the maxillofacial area (70486), breast tomosynthesis (77063), and screening mammography (77067) provided on June 28, 2018.
You asked the Plan to pay for the chest x-ray, CT scan of the maxillofacial area, breast tomosynthesis, and screening mammography. You say that the claim should be paid. The Plan denied your request. The Plan says the claim was not received within the 365 day timely filing period.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the chest x-ray, CT scan of the maxillofacial area, breast tomosynthesis, and screening mammography was not filed until October 11, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046), computed tomography (CT) scan of the maxillofacial area (70486), breast tomosynthesis (77063), and screening mammography (77067) provided on June 28, 2018.