Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that the records indicate a diagnosis of COPD, but the pulmonary function tests (PFTs) show restrictive disease. An arterial blood gases (ABG) test shows carbon dioxide (CO2) retention, but there is no diagnosis of neuromuscular
disease or thoracic restrictive disease. The CO2 retention is likely related, at least in part, to obesity hypoventilation syndrome and Medicare does not cover a ventilator for this diagnosis. The enrollee has been intolerant of BiPAP in the past. Intolerance is usually related to the noninvasive interface, which would be necessary for the ventilator; thus it is unlikely the enrollee will tolerate the ventilator. There is no demonstrated failure of BiPAP, and Medicare does not cover a ventilator when used as BiPAP. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns for tooth #'s 8, 9, and 10 provided on March 24, 2021.
You asked the Plan to pay for the crowns. You say that the enrollee was advised the day these services were rendered that only one crown would be covered at 50%. You also say that you would like all of the crowns to be covered at 50% as stated in the coverage brochure. The Plan denied your request. The Plan says appliances, surgical procedures, and restorations for replacing tooth structure loss resulting from attrition, abrasion, abfraction or erosion are not benefits of the 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. The Plan covers the crowns when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the crowns. Our reviewer says that the documentation provided was not sufficient to meet the criteria for coverage for crowns for tooth #'s 8, 9, and 10 of medically reasonable or necessary. Our physician reviewer found the documentation provided was not complete to determine if the criteria for coverage for crowns was met. The Plan also says that no x-rays were presented with the documentation to determine if the coronal breakdown was significant to warrant crown restorations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pay for the crowns for tooth #'s 8, 9, and 10 provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy 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 that a review of the current medical literature indicates that this service is considered experimental and investigational.
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 in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used for diagnosis as well as assessing treatment response. Bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met.
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
the services are not medically necessary. Our physician reviewer found the enrollee has paroxysmal atrial
fibrillation, heart failure, and a pacemaker for sick sinus syndrome. It is not documented that the enrollee is
enrolled in a prospective, national, audited registry that consecutively enrolls LAAC patients, and tracks the
following annual outcomes for each patient for a period of at least four years from the time of the LAAC:
Operator-specific complications, Device-specific complications including device thrombosis, Stroke,
adjudicated, by type, Transient Ischemic Attack, Systemic embolism, Death, and Major bleeding, by site and
severity. The LAAC is therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve left atrial appendage closure (LAAC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation (CPT code 99204) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the consultation. You say that you are needing to have this surgery done as soon as possible and this provider has the equipment needed to help you avoid being paralyzed from the waist down. The Plan denied your request. The Plan says the provider you requested is not part of your primary care physician's network. The Plan states Medicare only allows you to go out of your network for medical care that is not offered in the network. The Plan states your appeal tells the Plan that you want to see this doctor because they do robotic surgery. The Plan states Medicare coverage provides treatment for your illness but does not require medical groups to provide every conceivable treatment. Robotic surgery is only one technique for surgery. The Plan states the medical care you require is provided within your primary care physician's network.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the consultation (CPT code 99204) to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on October 15, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that the enrollee has never had to pay for ambulance transport in the past. The Plan denied your request. The Plan says there is no contract between the BLS ambulance, and the ALS ambulance that provided the paramedic intercept service.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the ALS paramedic intercept provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic intercept provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue, hard, (D7285) provided on April 13, 2021.
You asked the Plan to pay for the dental service. You say that you were not aware that the service would not be covered. The Plan denied your request. The Plan says the incisional biopsy of oral tissue is not listed as a covered service.
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 incisional biopsy of oral tissue is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue, hard, (D7285) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on March 17, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested item is not a benefit of Medicare or the Plan.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology (CPT code 88361) provided to the enrollee on April 6, 2021.
You asked the Plan to pay for the service. You say that the enrollee has been diagnosed with Barrett's Esophagus without dysplasia, a condition that indicates CDx testing is considered medically necessary. The Plan denied your request. The Plan says the diagnosis code (K22.70) reported on the claim does not support the necessity for code 88361.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provider billed the diagnosis code K22.70 Barrett's esophagus without dysplasia. The diagnosis code (K22.70) reported on the claim does not support the necessity for code 88361. The review has determined that items/services at issue in this case were 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 the service have not been met. Therefore, we decided that the Plan does not have to pay for morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology (CPT code 88361) provided to the enrollee on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP device (E0470, E0562).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical information to review against medically necessity.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the replacement BiPAP is considered not medically necessary because of lack of information to establish need. The appeal letter indicates that the device is not working properly because of excessive noise, and that a copy of the sleep study is provided, but that report is not found in the records. The date the device was originally provided is not found, and it appears the device has not been serviced by the vendor and deemed unrepairable. Thus, Medicare criteria for replacement are 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP device (E0470, E0562).
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for provision of test materials and equipment for home
INR monitoring. We decided that the Plan does not have to waive the copayment for provision of test materials
and equipment for home INR monitoring.
You asked the Plan to waive the copayment for provision of test materials and equipment for home INR
monitoring. You say that the services at issue should be processed with a $0 copayment. The Plan says that the
cost share was applied correctly.
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 20%
coinsurance for medical supplies.
The record shows that the Plan incorrectly applied a physician specialist copayment of $30 to the home INR
testing services at issue. Medicare rules are clear that these services fall within the Diagnostic Testing benefit
category. The Plan contract shows that there is a 20% coinsurance for diagnostic testing- medical supplies. The
allowed amount for the services at issue is $92.30. 20% of this is $18.46. Therefore, the Plan should charge
$73.84 ($18.46 x 4 dates of service = $73.84). 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 entire
copayment, but must reduce it from $30 to $18.46, per date of service.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging, any joint of upper extremity (73222) injection for dye for x-ray imaging of shoulder joint (23350) provided April 7, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that this appears to be a hospital bill. You were not in the hospital. You were in a clinic a few blocks away from the hospital. The Plan denied your request. The Plan says the claim was reprocessed with the correct copayment applied per the Evidence of Coverage.
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 $70 for
each diagnostic radiology service. You have been asked to pay $70 for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging, any joint of upper extremity (73222) injection for dye for x-ray imaging of shoulder joint (23350) provided April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epclusa tablet 400-100.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Epclusa tablet 400-100.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services (CPT code G0299 X 4), for the enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says records show that three (3) nursing visits have previously been approved to help the enrollee. The Plan states they have reached out to the home health agency for more records that support the need for home skilled nursing visits, and they have not received those records.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our physician reviewer found there is no documentation to support the need for skilled nursing services. There is no documentation that the enrollee is in need of any specific therapies for a specific condition. 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 pre-approve home health skilled nursing services (CPT code G0299 X 4), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
You asked the Plan to pre-approve BRCA testing. You say that you have family members that have a history of breast cancer. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not have a personal history of cancer so this is considered to be excluded screening testing.
The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is non-covered for testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. We looked at the file and Medicare rules. The record does not show that you have a personal history of a type of cancer for which this testing may be covered. Therefore, this request is considered screening which is excluded by Medicare statute. Based on this information, we decided that Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is to treat the enrollee's lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.