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

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.

You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452). You say that the enrollee needs this test. The Plan denied your request. The Plan says the enrollee underwent 3 stress tests in the past and all were negative for ischemia.

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 myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the local coverage determination states that imaging is not covered for asymptomatic patients unless the coronary calcium Agatston score >400.

In this case, the record indicates that the enrollee is asymptomatic and has had three negative stress tests in the past. The coronary calcium score is 137. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452) have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick external urinary collection system. 
 
You asked the Plan to pre-approve the Purewick system. You say that this is necessary for you as you are 
having to get up at night to go to the bathroom. The Plan denied your request. The Plan says this is not covered 
for a patient without permanent urinary incontinence. 
 
The Plan must follow Medicare rules. Medicare rules say that a urinary collection system, such as the 
Purewick, is covered for beneficiaries who have permanent urinary incontinence when used as an alternative to 
an indwelling catheter. 
 
The documentation shows you do not have permanent incontinence nor that you would otherwise need to use 
an indwelling catheter. Therefore, we decided that the Plan does not have to pre-approve a Purewick external 
urinary collection system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that you are appealing the denial 
for additional physical therapy sessions. The Plan denied your request. The Plan says additional visits are not 
medically necessary. 
 
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 pre-approve additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the patient has had little improvement in her 
condition with twenty-four physical therapy sessions. Our reviewer says that further skilled therapy is not 
likely to achieve any significant improvement in the patient's symptoms or functional status and further 
utilization of the home exercise program is more appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on February 25, 2020.
You asked the Plan to pay for vision services. You say that you had an eye exam, and you have vision exam benefits with your plan. The Plan denied your request. The Plan says this provider is out of network with the Plan and prior authorization was not obtained.
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 vision services provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on April 21, 2021.

You asked the Plan to pay for vision services. You say that the enrollee did not have any input in choosing an optometrist. You also say the provider is not responsible for obtaining authorization for services at a nursing home. The Plan denied your request. The Plan says this provider is out of network with the Plan and prior authorization was not obtained.

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 vision services provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network provider.
You asked the Plan to pre-approve dialysis services to be provided by an out of network provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 dialysis services to be provided by an out of network provider. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee is on dialysis. The case file indicates that in network facilities are available for the enrollee. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. Therefore, the enrollee does not meet criteria to receive the requested services from an out-of-network provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dialysis services to be provided by an out of network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and deep cleaning to be performed by a
periodontist.
You asked the Plan to pre-approve the dental services. You say that you need the cleaning. You say that your
mouth hurts. You also say that you have bad breath due to not having the cleaning done. The Plan denied your
request. The Plan says dental services to be performed by a periodontist are not covered.
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 services are not among
those covered under this benefit if they are provided by a periodontist. Therefore, we decided that the Plan does
not have to pre-approve a consultation and deep cleaning to be performed by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray, comprehensive oral evaluation, scaling in presence of gingival inflammation and unspecified periodontal procedure provided on May 18, 2021.

You asked the Plan to pay for the intraoral complete series x-ray, comprehensive oral evaluation, scaling in presence of gingival inflammation and unspecified periodontal procedure. You say that the network status should have been researched prior to the appointment. You say that you were under the impression this would be covered. The Plan denied your request. The Plan says out-of-network dental services are not covered.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray, comprehensive oral evaluation, scaling in presence of gingival inflammation and unspecified periodontal procedure provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation treatment (77427) and CT guidance for the 
placement of radiation therapy fields (77014) provided on March 1, 2021, through March 26, 2021. 
 
You asked the Plan to pay for the radiation treatment and CT guidance. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
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 77427 is radiation treatment management, 5 treatments.  
 
the CPT Code Manual definition of code 77014 is Computed tomography guidance for placement of radiation 
therapy fields.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 24, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You did not provide an argument for coverage in your appeal request. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 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 medical services provided on November 24, 2020 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction (D7140) of tooth #31.
You asked the Plan to pre-approve the extraction (D7140). You say that the issue is medical due to the possibility of an infection. The Plan denied your request. The Plan says the service 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 the extraction (D7140) of tooth #31
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mini massager (A9270).
You asked the Plan to pre-approve a mini massager. You say that you are appealing the denial f the items which would relieve pain in both hands caused by osteoarthritis and osteoporosis. The Plan denied your request. The Plan says this item is a personal comfort item and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a mini massager (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an OON provider.
You asked the Plan to pre-approve a consultation. You say that you would like the plan to reconsider their
denial The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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
a consultation to be provided by an OON provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have reached reasonable expectations for improvement and are medically stable.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from October 11, 2021, forward, were requested. 

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 continued services. Our physician reviewer found that the services for the dates in question were not reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. It was not expected you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others.

You did not have auditory or visual hallucinations and were without aggressive behaviors. You were not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care attendant services.
You asked the Plan to pre-approve personal care attendant. You say that you are trying to get the best care for
the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because a personal care attendant is custodial care which is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of personal care attendant have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve
personal care attendant services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert device (A9280). 
 
You asked the Plan to pre-approve an alert device. You say that it is necessary for you to have an emergency 
communication system as it is hard for your wife to pick you up. The Plan denied your request. The Plan says 
this is not a covered benefit according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that alert systems are emergency communications 
systems and do not serve a diagnostic or therapeutic purpose.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an alert device have not been met. Therefore, we decided that the Plan does not have to pre-
approve an alert device (A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #26.
You asked the Plan to pre-approve endodontic therapy for tooth #26. The Plan denied your request. The Plan says the service 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 endodontic therapy for tooth #26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery consultation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the vascular surgery consultation. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-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. The records provided for review do not show that the service at 
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the vascular 
surgery consultation to be provided 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 core buildup, including any pins when required (D2950) for tooth 6, 7, 8, 10 and 11, crown - porcelain/ceramic (D2740) for tooth 6, 7, 8, 10 and 11 provided May 28, 2021.

You asked the Plan to pay for the core buildup and crowns for tooth 6, 7, 8, 10 and 11. You say that you would like the services covered. The Plan denied your request. The Plan says you have exhausted your dental benefit for the year.

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 core buildup and crowns up to the maximum plan benefit coverage amount of $1,000 per year for all supplemental dental services covered by the Plan. 

We looked at the file and Medicare rules. The Plan has provided dental coverage up to the maximum $1,000 limit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) for tooth 6, 7, 8, 10 and 11, crown - porcelain/ceramic (D2740) for tooth 6, 7, 8, 10 and 11 provided May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Yervoy (ipilimumab) with oral 
cabozantinib. 
 
You asked the Plan to pre-approve the Yervoy treatment. You say that this treatment should be allowed. The 
Plan denied your request. The Plan says the requested treatment is not supported in the peer-reviewed 
literature. 
 
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 the Yervoy treatment. Our reviewer 
says that the use of Yervoy in this situation is not considered medically reasonable and necessary. Our 
physician reviewer found Yervoy is only FDA-approved for treatment of renal cell carcinoma in combination 
with nivolumab for four cycles, followed by nivolumab monotherapy until there is disease progression or 
unacceptable toxicity. The requested use is not supported in the Medicare-approved compendia or medical 
journals.

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 Yervoy treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Yervoy (ipilimumab) with oral cabozantinib.