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

We decided that the Plan does not have to pre-approve the power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0843), legrest (E1012), headrest (E0955), power seating system (E1007), swingaway (E1028), seatframe (E2341), harness (E2313), battery (E2361), expandable controller (E2377), and seat cushion (E2602).
You asked the Plan to pre-approve the power wheelchair, group 2 heavy duty, multiple power option and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair, group 2 heavy duty, multiple power option and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the patient has a mobility deficit, but the physician documentation does not clearly indicate that this deficit impairs MRADLs in the home and is not ameliorated by a walker. There is no clear description in the physician progress notes of specific MRADL limitation and the physician documentation does not reveal that the patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management or needs a power seating system to manage increased tone or spasticity. It is not medically necessary to control the requested power options through the joystick (drive interface); the patient's strength and functional ability in the upper extremities with independence in eating should be sufficient to control any power options through their own switches. 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 power wheelchair, group 2 heavy duty, multiple power option and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0843), legrest (E1012), headrest (E0955), power seating system (E1007), swingaway (E1028), seatframe (E2341), harness (E2313), battery (E2361), expandable controller (E2377), and seat cushion (E2602).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve 150 additional test strips per month for high utilization testing.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that additional test strips are 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 medically necessary. Our physician reviewer found the enrollee is prescribed more than three test strips per day, which is standard for an insulin-treated patient. Although there is no blood glucose log, she is on a complex regimen of a basal and a three times per day mix, so monitoring blood glucose more often is the standard of care and makes clinical sense for this enrollee. The additional test strips are 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 these services have been met. Therefore, we decided that the Plan has to pre-approve 150 additional test strips per month for high utilization testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on June 16, 2021.
You asked the Plan to pay for the CT scan of the head or brain. You say that the medical documentation supported the services as billed. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.
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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on March 24, 2021.
You asked the Plan to pay for the hearing aids. You say that this was a limited time offer and would save the Plan almost $2,000 and save you $3,200. You say that the old ones were still under guarantee and this should be an approved vendor. The Plan denied your request. The Plan says the hearing aids were not purchased through the Plan hearing vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from the Plan's hearing vendor. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 28, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 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 this is considered to be experimental, investigational, and unproven.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this procedure is the subject of on-going clinical trials and is considered experimental/
investigational. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the insulin treatment regimen does not require frequent adjustment by the enrollee based on testing results.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided on June 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, and intraoral periapical x-rays. You say that your previous visit to this same dentist was paid, and you are wondering why this claim was denied stating the provider is OON. The Plan denied your request. The Plan says these services
were rendered by a non-participating provider. The Plan also says that services provided by an OON provider are not covered under your plan 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral exam (D0140) provided on October 29, 2020.
You asked the Plan to pay for the dental service. You say that this was not an anticipated problem. You say that your crown fell out. You also say that this was an emergency situation. The Plan denied your request. The Plan says 1 emergency oral exam is covered every 12 months. The Plan also says that the frequency limit has been exceeded.
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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral exam that you
received on July 2, 2020. Therefore, we decided that the Plan does not have to pay for the emergency oral exam (D0140) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99291) provided on April 17, 2021, and April 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not supported.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes".
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes of critical care services were provided on the dates of service in question. 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 services (99291) provided on April 17, 2021, and April 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 this drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug and (IV) Zoledronic Acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services and exam services provided in a chiropractic setting from May 10, 2021 to May 13, 2021.
You asked the Plan to pay for these services. . You say that these services should be covered by the Plan. The Plan denied your request. The Plan says imaging services and exam services other than manual manipulation of the spine are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for imaging services and exam services provided in a chiropractic setting from May 10, 2021 to May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675)
provided on April 16, 2021.
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices
are not covered by Medicare for prevention of venous thromboembolism.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression
devices (E0673, E0675) provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 10, 2021.

You asked the Plan to pay for the refraction. You say that it is reasonable to assume that when a plan provider
refers a patient to another plan provider that the service will be covered. You say that you were not informed
the services would not be covered and the denial of payment should be reversed. The Plan denied your request.
The Plan says eye refractions are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eye exams, eye
refractions or eyeglasses/contacts.

The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that
the Plan does not have to pay for the refraction provided on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary as it is considered experimental for the enrollee's condition.

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 Opdivo. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found you have been diagnosed with metastatic clear cell kidney cancer. You have previously progressed on treatment with Keytruda. In this case, the requested drug is not FDA-approved for the enrollee's condition. Furthermore, the use of the requested drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. While there is support for Opdivo providing antitumor activity with acceptable toxicity in patients with metastatic renal cell carcinoma, this is only when prescribed in combination with Yervoy. This request can be resubmitted with a request for Yervoy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the panoramic x-ray (D0330) provided on
June 9, 2021.

You asked the Plan to pay the in network rate for the panoramic x-ray. You say that you were advised prior to
your appointment that the provider was in network. The Plan denied your request. The Plan says panoramic x-ray
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 panoramic x-ray is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate
for the panoramic x-ray (D0330) provided on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because the LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested genetic testing is not medically reasonable and necessary. Our physician reviewer found that there is insufficient documentation to demonstrate that the PGx1 Comprehensive Panel ordered on May 12, 2021, was medically reasonable and necessary for the enrollee in this case. It has not been demonstrated that this testing would impact the management and outcome of the enrollee's medical 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on April 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no record of a consultation with the PCP.
The Plan must follow Medicare rules. Medicare rules say that the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. The records provided do not show that the CP consulted the enrollee's attending or PCP. 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 outpatient mental health services provided on April 14, 2021.