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

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided
on June 29, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you were not aware that
the provider did not accept your Plan. You also say you are on a fixed income and would appreciate this
problem rectified. The Plan denied your request. The Plan says the requested provider has opted out of
Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on January
22, 2016. This means that the provider was opted out of Medicare for the date of service at issue. Therefore, we
decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on
June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service
needs. here are identifiable skilled nursing service needs. The enrollee does not require skilled nursing or
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria
for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections at three levels bilaterally, L3-S1.

You asked the Plan to pre-approve the three-level facet joint injections. You say that the enrollee should be approved for this medically necessary procedure. The Plan denied your request. The Plan says the LCD limits facet joint injection to two levels unless documentation supports a unique circumstance where more are necessary. This is not documented in this case.

The Plan follows Medicare rules. Medicare rules say that, for facet joint injections, one to two levels, either unilateral or bilateral, are allowed per session per spine region. A three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. 

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 three-level facet joint injections. Our reviewer says that the requested number of facet joint injections is not shown to be medically reasonable and necessary. Our physician reviewer found the clinical documentation provided does not included any documentation that relates and/or substantiates the need for additional injections at multiple levels in the same procedure The review has determined that the enrollee does not have a covered indication for the requested 3-level bilateral lumbar medial branch blocks as requested. 

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 three-level facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections at three levels bilaterally, L3-S1.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided to the enrollee
on August 3, 2021.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0482 (1 Unit)
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the
specimen was collected on August 3, 2021, and received by the lab on August 5, 2021. Therefore, the billed
code cannot be verified. It is noted multiple attempts were made to obtain additional information from the
provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0482)
provided to the enrollee on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

we decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that you are in a lot of pain and
need this taken care of. You say that you do not want to live on pain pills. The Plan denied your request. The
Plan says the service requested has not been proven to be helpful by research. The Plan says that the requested
services are not medically necessary. The service requested has not been proven to be helpful by research. The
Plan says that the requested services are 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 pre-approve radiofrequency ablation services. Our
reviewer says that radiofrequency ablation services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the requested services are deemed an experimental and investigational
procedure because of the wide variation in efficacy reported in the literature. Therefore, the request is deemed
not medically reasonable or necessary.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa) injections.
You asked the Plan to pre-approve the Aranesp injections. You say that this is medically necessary to treat the
enrollee's anemia. The Plan denied your request. The Plan says the enrollee's test results do not show anemia
requiring treatment with Aranesp. The records and the claims history do not show that this has been provided
within the last six months.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Aranesp injections. Our reviewer
says that the requested drug is not medically necessary in this case. Our physician reviewer found the enrollee
is a male with anemia secondary to chronic kidney disease. His most recent hemoglobin/hematocrit is 10.7/33.
This level does not support the use of Aranesp at this time.
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 Aranesp injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Aranesp (darbepoetin alfa) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on November 30, 2020.
You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says prior
authorization was not obtained by the provider or facility.
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 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 ophthalmological services provided on November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care, from February 21, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that the enrollee needs more time to recover. The Plan denied your request. The Plan says the enrollee has plateaued with therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee needs more time to recover. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care, from February 21, 2022, forward.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and a Coronavirus vaccine provided on
June 10, 2021.
You asked the Plan to pay for an office visit and a Coronavirus vaccine. The Plan denied your request. The
Plan says the claim needed to be reprocessed due to the provider previously being participating.
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 an office visit on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve luspatercept-aamt, 0.25mg injection (CPT code J0896),
for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee does not satisfy cited coverage criteria.
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 the medication. Our physician reviewer
found the requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis. There is no bone
marrow done to confirm type of myelodysplastic syndrome. The use is not supported by one of the major drug
compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of
CMS-approved 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 medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve luspatercept-aamt, 0.25mg injection (CPT code J0896), for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your
request. The Plan says that the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
enrollee meets criteria for SNF care. Our physician reviewer found the enrollee has documented skilled nursing
and skilled therapy needs. The enrollee's therapy needs can be met on an intermittent basis. Daily skilled
services are required to establish a maintenance program and/or prevent deterioration of the enrollee's
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 SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Prolia (denosumab) injections.  You asked the Plan to pre-approve the Prolia injections. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's risk of fracture is low enough to support using other drugs prior to starting Prolia.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia injections. Our reviewer says that the requested Prolia is medically necessary. Our physician reviewer found the enrollee is a female with osteoporosis as documented by imaging. Her provider has recommended medical therapy with Prolia. Denosumab (trade names Prolia and Xgeva) is a human monoclonal antibody for the treatment of osteoporosis, treatment-induced bone loss, metastases to bone, and giant cell tumor of bone. Denosumab is contraindicated in people with low blood calcium levels. The most common side effects are joint and muscle pain in the arms or legs. The review has determined that the documentation supports that the Prolia is medically reasonable and necessary for the patient. The documentation supports that the Prolia is safe and effective for the patient.  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 Prolia injections have been met. Therefore, we decided that the Plan has to pre-approve Prolia (denosumab) injections.   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: SNF
Decision: Unfavorable

The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original
Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or
suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the
enrollee's hospice election until the first day of the month after the hospice election has been revoked or
terminated. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual,
Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.4.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com The Plan contract says that the Plan covers items and services in accordance with Medicare rules
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that you need the therapy and exercise to get better
and stronger. The Plan denied your request. The Plan says the SNF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the provided
documentation does not show that you have daily skilled nursing needs that require the specialized skill,
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF admission have not been met. Specifically, the file does not show that you
require daily skilled services. Therefore, we decided that the Plan does not have to pre-approve a skilled
nursing facility (SNF) admission
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), and panoramic x-ray
(D0330) provided on October 6, 2021.
You asked the Plan to pay for the dental services. You say that your dentist retired. You say that you received a
bill for $200. You also say that this should be paid. The Plan denied your request. The Plan says that the
frequency limits have been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the file shows that these services were denied for the frequency
limit being exceeded. We requested documentation to support these claims. The documentation that we
received still does not support that the frequency limits for these services have been exceeded. Therefore, we
decided that the Plan has to pay for the comprehensive oral evaluation (D0150), and panoramic x-ray (D0330)
provided on October 6, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis represented by code L1845.
You asked the Plan to pre-approve the knee orthosis. You say that the clinical information provided supports
the need for the requested orthoses. The Plan denied your request. The Plan says the records do not show that
the enrollee had a recent injury or a surgical procedure on the knees. The Plan says that the records document
the physical exam performed by the enrollee's physician which stated that all ligaments appear stable, and that
there was no significant laxity noted. The Plan says that the requested knee orthoses is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that knee orthoses will be covered for certain medical
indications and when 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 knee orthosis. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documented knee
instability of fracture. A knee brace is not medically reasonable or necessary in this case.
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 knee orthosis have not been met. Therefore, we decided that the Plan does
not have to pre-approve a knee orthosis represented by code L1845