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

We decided that the Plan does not have to pre-approve dental services (D6740).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 dental services (D6740).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Pylarify injection during PET for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation of the use of this imaging in standard work of a newly diagnosed prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that PET 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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee has a new diagnosis of prostate cancer with suspected mets. Per the package insert, Pylarify is approved with PET for patients with suspected mets who are candidates for initial definitive 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve a Pylarify injection during PET for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the hip you had on April 15, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you had an office visit on the same date so the copayment for the office visit should be the only thing you have to pay. The Plan denied your request. The Plan says you were charged this copayment. The Plan says that because the allowed amount for this service ($42.88) is less than your copayment obligation, you are responsible for the full allowed amount.
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 $50 copayment for each x-ray you have in a provider's office. You have been asked to pay a $50 copayment for the x-ray. Your contract explicitly states that you pay this
copayment even if you get the x-ray in a provider's office. 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 the x-ray of the hip you had on April 15, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Bioness Go Lower and a Bioness Go Thigh Plus 
functional electrical stimulation systems. 
 
You asked the Plan to pre-approve a Bioness Go Lower and a Bioness Go Thigh Plus. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage 
for the requested items have not been met. 
 
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 a Bioness Go Lower and a Bioness Go 
Thigh Plus. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the requested service is only covered for patients with a history 
of spinal cord injury (SCI) who have undergone surgery. In this case, you do not have a history of a SCI. You 
have been prescribed a functional electrical stimulation system for changes due to their multiple sclerosis. 
 
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 Bioness Go Lower and a Bioness Go Thigh Plus have not been met. Therefore, we decided that the Plan does not have to pre-approve a Bioness Go Lower and a Bioness Go Thigh 
Plus functional electrical stimulation systems.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies
(95909), and digital analysis of electroencephalogram (95957) provided on January 14, 2021.
You asked the Plan to pay for needle electromyography, nerve conduction studies, and digital analysis of
electroencephalogram. You say that these services were billed correctly. The Plan denied your request. The
Plan says these codes are not documented.
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 95886 is needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List
separately in addition to code for primary procedure).
The definition of 95909is nerve conduction studies; 5-6 studies. The definition of 95957 is digital analysis of
electroencephalogram (EEG) (eg, for epileptic spike analysis).
We asked our coder 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 needle electromyography, nerve conduction studies, and
digital analysis of electroencephalogram. Our reviewer says that these codes are not supported by the records.
Our reviewer found code 95909 is not supported because the technical report documents a stimulating probe
was used to deliver electrical current. Nerve conduction studies are performed with electrodes and should not
be reported for pedical screw stimulation. Code 95957 is not supported because the technical report documents
that "real time" Electroencephalogram monitoring was performed. CPT 95957 is an incorrect code to report for
"real time" electroencephalogram monitoring. Code 95886 cannot be covered as there were no nerve
conduction studies performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography, nerve conduction studies, and digital analysis of
electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle
electromyography (95886), nerve conduction studies (95909), and digital analysis of electroencephalogram
(95957) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the enrollee to be approved for an admission to an IRF because they are due to be discharged in a few days. The Plan denied your request. The Plan says your request is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled care provided on May 1, 2020, to May 18, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the skilled care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the care provided was custodial care.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the skilled care provided on May 1, 2020, to May 18, 2020, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 21, 2021.

You asked the Plan to pay for physical therapy. You say that you submitted the Waiver of Liability along with supporting documents. The Plan denied your request. The Plan says the physical therapy is not covered.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 physical therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient was referred for balance and vestibular training, but the documentation does not reveal that the patient was receiving vestibular rehabilitation. Our reviewer found that the patient was treated for low back and neck pain. Our reviewer says that the unique skills of a professional therapist were not required to safely and effectively provide treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed (E0250) purchased April 27, 2021, from a provider not certified with Medicare.
You asked the Plan to pay for the hospital bed. You say that you would like to be reimbursed for this equipment as this was medically necessary. The Plan denied your request. The Plan says this provider is not certified with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the hospital bed (E0250) purchased April 27, 2021, from a provider not certified with Medicare.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2020.

You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal 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 the laboratory services provided on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (vedolizumab), 1 mg.

You asked the Plan to pre-approve Entyvio. You say that although this medication is not indicated for the enrollee's diagnosis, there is substantial documentation supporting its use. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Entyvio. Our reviewer says that Entyvio (vedolizumab) is not medically necessary. Our physician reviewer found the requested use of Entyvio is not FDA-approved for the enrollee's diagnosis. The reviewer found that the use of vedolizumab for the treatment of the enrollee's diagnosis is not supported in the major drug compendia. There is insufficient support in the medical literature for the use of vedolizumab in the treatment of the enrollee's diagnosis. Therefore, the reviewer found that the requested drug, Entyvio, is not medically reasonable or 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 Entyvio have not been met. Specifically, the requested use of this drug is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Entyvio (vedolizumab), 1 mg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Portrazza (J9295).

You asked the Plan to pre-approve Portrazza. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested drug have not been met.

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 Portrazza. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found you have been diagnosed with squamous cell carcinoma of the lung. In this case, you have received prior lines of therapy and Portrazza is only FDA approved in combination with Cisplatin and Gemcitabine. Therefore, the requested use is not FDA-approved for your diagnosis. In addition, the use of Portrazza is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Portrazza have not been met. Therefore, we decided that the Plan does not have to pre-approve Portrazza (J9295).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided June 2, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the enrollee was enrolled in hospice care so Original Medicare would be responsible for payment of these services.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pre-approve a Prius Healthcare rhythm tum lateral rotation mattress. You say that this 
request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is 
considered a convenience item that exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is subject to the criteria 
listed in the Medicare rules section. 
 
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 Prius Healthcare rhythm tum lateral 
rotation mattress. Our reviewer says that the requested equipment is not medically reasonable and necessary. 
Our physician reviewer found The documentation does not reveal on an objective physical examination that the 
patient has multiple stage 2 pressure ulcers located on the trunk or pelvis  which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program. The 
exam notes only erythematous rashes. There is no evidence on an objective physical exam of large or multip le 
stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on 
the trunk or pelvis within the past 60 day. Furthermore, the Prius Healthcare rhythm tum lateral rotation 
mattress also exceeds the patient's needs as this product has convenience items that are not medically necessary 
for ulcer healing such as the Auto Firm Feature and the 10 Digital comfort setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Prius Healthcare rhythm tum lateral rotation mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Prius Healthcare rhythm tum lateral rotation 
mattress. We decided that the Plan does not have to pre-approve a Prius Healthcare rhythm tum lateral rotation mattress.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on March 1, 2021.

You asked the Plan to pay 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 were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services rendered by the out-of-network (OON) provider on
March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on March 23, 2021. 
 
You asked the Plan to pay for the physical therapy services. 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 as billed. 
 
Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-
physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services.Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on March 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve the requested service. You say that the service is medically necessary based on spondylosis with myelopathy, lumbar region. The Plan denied your request. The Plan says the enrollee's current pain level has not been received.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are only covered under certain medical indications. 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 service. Our physician reviewer found that the enrollee has chronic low back pain. He had an ESI on November 3, 2020, which provided good relief. He takes Norco for pain. His magnetic resonance imaging (MRI) shows multi-level degenerative changes. There is no recent physical exam, physical therapy, or other conservative therapies. The request does not meet the coverage criteria. Therefore, the request is deemed not medically reasonable or necessary at this point. 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 requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.