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

We decided that the Plan does not have to pre-approve a retainer crown (D6751) and a false tooth for a bridge (D6240).
You asked the Plan to pre-approve a retainer crown and a false tooth for a bridge. You say that you are having a hard time eating and have an infected tooth. You also say you need to have the service done as soon as possible. The Plan denied your request. The Plan says services are not medically necessary.
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 a retainer crown and a false tooth for a bridge 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 pre-approve a retainer crown and a false tooth for a bridge. Our reviewer says that the service is not medically necessary. Our physician reviewer found that placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. The placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth to replace a single maxillary anterior tooth or replace two adjacent mandibular teeth. Fixed prosthetic appliances are not a benefit when there is one or more missing posterior teeth in the same arch. The documentation is insufficient to support that the requested D6240 for tooth 5, and D6751 for tooth numbers 4 and 6 are medically reasonable and necessary for the enrollee in this case. 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 a retainer crown and a false tooth for a bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6751) and a false tooth for a bridge (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that a basic pump would not be effective for the enrollee. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening colonoscopy billed for date of services September 8, 2020.
You asked the Plan to pay for the screening colonoscopy. You say that the claim was correctly billed. The Plan denied your request. The Plan says the upper endoscopy codes were paid based on the records provided. However, there is no record supporting payment for the colonoscopy.
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 G0105 is Colorectal cancer screening; colonoscopy on individual at high risk.
We find that CPT code G0105 is not supported in the medical record. Specifically, there is nothing in the record provided that indicates that a colonoscopy was planned or performed. Based on this information, we decided that Medicare rules for coverage of the screening colonoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the screening colonoscopy billed for date of services September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth number 27.
You asked the Plan to pre-approve endodontic therapy. You say that the enrollee is in severe pain. The Plan denied your request. The Plan says the requested services are 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. The Plan covers endodontic therapy when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy for tooth number 27.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gocovri.
You asked the Plan to pre-approve Gocovri. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Gocovri.
Benefits for Gocovri may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemical 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 chemical ablation is not considered medically reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that chemical ablation is not considered medically reasonable or necessary. The requested modality for radiofrequency ablation is not covered by Medicare at this time. 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 a chemical radiofrequency ablation for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Paclitaxel Proteinbound Particles.
You asked the Plan to pre-approve Keytruda, Carboplatin, and Paclitaxel Proteinbound Particles. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Keytruda, Carboplatin, and Paclitaxel Proteinbound Particles. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 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 Keytruda, Carboplatin, and Paclitaxel Proteinbound Particles have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Paclitaxel Proteinbound Particles
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital stay.
You asked the Plan to pre-approve an acute inpatient hospital stay. You say that the enrollee underwent a lateral partial meniscectomy in February 2019 which gave the enrollee no relief. The enrollee has some difficulty getting out of a low chair. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an inpatient hospital stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 an acute inpatient hospital stay. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital stay is met in this case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an acute inpatient hospital stay have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital stay.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iron infusion.
You asked the Plan to pre-approve iron infusion. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 iron infusion. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the review has determined that the
documentation does not support that the iron infusion is medically reasonable and necessary for the enrollee.
The documentation does not support that the iron infusion is safe and effective 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 iron infusion have not been met. Therefore, we decided that the Plan does not
have to pre-approve iron infusion
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is an electro-acupuncture device, which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. The requested device is considered an auricular stimulator. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve a seat lift mechanism. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer says that the services are not medically necessary. Our physician reviewer found the seat lift is not likely to (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's condition. The records do not show that the enrollee is totally incapable of standing from a chair in the home. The enrollee is using a wheelchair and is non weight bearing. There is no description or reference to the enrollee's ability to ambulate in the documentation. The enrollee does not meet the criteria for the seat lift mechanism. 

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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (63047) provided September 11, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the procedure code billed cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 63047 is not supported in the medical record. Specifically, per the CMS National Correct Coding Initiative manual, chapter 4, CMS payment policy does not allow separate payment for CPT codes 63042 or 63047 with CPT codes 22630 or 22633 when performed at the same interspace. The procedures were performed in the same anatomical space and the plan has agreed to pay CPT code 22630. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (63047) provided September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Supartz injections (J7321, 20611) provided May 17, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided.
The Plan must follow Medicare rules. Medicare rules say that the patient's medical record should contain documentation that fully supports the medical necessity for intra-articular injections. We looked at the file and Medicare rules. Only one page of records documenting the procedure was provided. The plan requested additional records, and none were provided. Based on this information, we decided that
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for Supartz injections (J7321, 20611) provided May 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve nasopharyngoscopy.

You asked the Plan to pre-approve nasopharyngoscopy. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

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 nasopharyngoscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case has persistent symptoms despite surgical and medical therapies over many years. Current studies support that Eustachian tube balloon dilation can be a helpful procedure for patients with Eustachian tube dysfunction. The evidence supports that the procedure is safe and effective in this 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 nasopharyngoscopy have been met. Therefore, we decided that the Plan has to pre-approve nasopharyngoscopy.

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 group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for a group 3 power wheelchair.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. The Plan says they will approve a group 2 power wheelchair if requested. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient visits with an out-of-network provider.

You asked the Plan to pre-approve the outpatient visits with an out-of-network provider. You say that you would like reconsideration because more exams are needed for your condition and changing providers could jeopardize your health. The Plan denied your request. The Plan says this provider is no longer a part of your plan's network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient visits with an out-of-network provider have not been met. Specifically, the record indicates that the Plan has approved 5 outpatient visits with this provider. The record also indicates that there are providers available in the Plan's network who can render the requested services. Therefore, we decided that the Plan does not have to pre-approve the outpatient visits with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you test your blood sugar four times a day and need the assistance of the CGM. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or use an insulin pump. 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 a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93971) provided April 9, 2021.

You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 93971 is not supported in the medical record. Specifically, per Medicare Local Coverage Article (LCA): Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993), Z03.89 is not listed as a covered diagnosis for this procedure.

Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (93971) provided April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81307, 81406, 81408, 81479) provided May 25, 2021.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary due to your oncological history and may alert other family members to risk. The Plan denied your request. The Plan says this testing is only covered once per lifetime.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is limited to once-in-a-lifetime. We looked at the file and Medicare rules. The record shows previous genetic testing. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81307, 81406, 81408, 81479) provided May 25, 2021.