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

We decided that the Plan does not have to pay for a revascularization of the iliac artery for each additional ipsilateral iliac vessel (37222) and an abdominal aortography (75625) provided on February 16, 2021.
You asked the Plan to pay for a revascularization of the iliac artery for each additional ipsilateral iliac vessel and an abdominal aortography. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provided records do not support the services 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 37222 is "Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)." The CPT Code Manual definition of code 75625 is "Aortography, abdominal, by serialography, radiological supervision and interpretation." We asked our coder 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 a revascularization of the iliac artery for each additional ipsilateral iliac vessel and an abdominal aortography. Our reviewer says that the billed services do not meet criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty was performed on February 16, 2021; therefore, this service cannot be verified. The medical records provided do not include sufficient documentation to support that an Aortography, abdominal, by serialography, radiological supervision and interpretation was performed as an independent procedure; therefore, this procedure cannot be verified and is not eligible for separate reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a revascularization of the iliac artery for each additional ipsilateral iliac vessel and an abdominal aortography have not been met. Therefore, we decided that the Plan does not have to pay for a revascularization of the iliac artery for each additional ipsilateral iliac vessel (37222) and an abdominal aortography (75625) provided on February 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee is physically weak, is a falling hazard, and needs SNF care. The Plan denied your request. The Plan says 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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical removal of erupted tooth requiring removal of bone
and/or sectioning of tooth and including elevation of mucoperiosteal flap (D7210) extraction, erupted tooth, or
exposed root (D7140) and conscious sedation (D9230) provided June 7, 2021, to June 23, 2021.
You asked the Plan to pay for the dental services. You say that the teeth had to be extracted because of the
damage done by chemo and radiation. The Plan denied your request. The Plan says the services exceed the
annual maximum benefit limitation. The annual limit has been allowed by the dental Plan for this benefit 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 rules say a plan must
disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles,
and coinsurance). Your contract with the Plan clearly says that you must pay any amount over the $265 dental
benefit allowance. The records show that the Plan had paid the $265 dental allowance on dates of service
February 15, 2021($144), April 6, 2021 ($58), and April 16, 2021 ($63).
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 as the benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth
and including elevation of mucoperiosteal flap (D7210) extraction, erupted tooth, or exposed root (D7140) and
conscious sedation (D9230) provided June 7, 2021, to June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture and erupted tooth extraction.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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 items or services are not among those covered under this benefit. The tooth extraction is not covered by your medical benefit because it is not being done to prepare the jaw for radiation treatments. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture and erupted tooth extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home blood pressure monitor.
You asked the Plan to provide coverage for a home blood pressure monitor. You say that your doctor would like you to monitor your blood pressure at home. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis. You are not on home dialysis. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide coverage for a home blood pressure
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts (L3020).

You asked the Plan to pre-approve foot inserts. You say that you need to replace your previous inserts. The Plan denied your request. The Plan says these items are not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3020).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tepezza.

You asked the Plan to pre-approve Tepezza. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

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 Tepezza. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm. The submitted records provide insufficient detail to establish the diagnosis of Graves Orbitopathy (thyroid eye disease). The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have to pre-approve Tepezza.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the enrollee to receive acute rehabilitation. You also say that the plan wants the enrollee to be moved to a sub-acute facility and have a feeding tube placed. The Plan denied your request. The Plan says the requested services are not medically necessary at this time.
The Plan must follow Medicare rules. The rules say that inpatient rehabilitation facility (IRF) admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Therefore, the reviewer found that the requested IRF admission is not 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 IRF care have not been met. Specifically, the file does not show that the enrollee requires the intensity of services provided at an IRF. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophagastroduodenoscopy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the symptoms are well controlled.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support that the enrollee meets the evidence-based guidelines for the requested procedure at this time. The enrollee's dyspepsia is well controlled on omeprazole and there are no red flags to warrant esophagastroduodenoscopy in the charts. In addition, the enrollee has been screened negative for Barrett's esophagus.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve esophagastroduodenoscopy for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography, a special kind of picture of your colon for screening (74263).
You asked the Plan to pre-approve the colonography. You say that this service is necessary. The Plan denied your request. The Plan says computed tomography colonography is not indicated for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography (CTC) is a nationally non-covered indication. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the colonography have not been met. Specifically, the requested service is not covered for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) colonography, a special kind of picture of your colon for screening (74263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #12.
You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950). You say that the tooth has recurrent decay around the old amalgam and fractures. You say that once the old restoration is removed, the buildup and crown will be necessary. The Plan denied your request. The Plan says the services are not covered benefits.
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 crown (D2740) and core buildup (D2950) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and porcelain/ceramic crown (D2740).
You asked the Plan to pre-approve the dental services. You say that you would like a review of the attached information and reprocessing of the predetermination. The Plan denied your request. The Plan says the provider has not submitted any narrative documentation to support a core build-up and crowns are not covered for cosmetic reasons or for closing gaps.
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 dental services 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 the dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in the case presented the only reason for the requested crown would be to close the gap between the teeth #13 and #14. Due to the specific limitations of the Plan, there would not be coverage for replacement of #13 for the sole purpose of closing the gap between that tooth and #14. Core buildups are only considered in cases where a crown is to be placed and there is insufficient structure to retain that crown. Accordingly, if there is no crown to be approved, the buildup is not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and porcelain/ceramic crown (D2740).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lower extremity joint
for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not recommended for assessment of nerve damage.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has
documented left peroneal nerve damage at or around the left knee. As such it is important to examine the
tissues surrounding the nerve to determine if there is a soft tissue or boney structure which may be impinging
upon the nerve and MRI is the best technique for such evaluation.
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
magnetic resonance imaging (MRI) of the lower extremity joint for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have right ankle, right hand, and left knee fractures after a motor vehicle accident. There is documentation that your condition requires positioning of the body in ways not feasible in an ordinary bed and special attachments that cannot be fixed to an ordinary bed. There is no documentation that you require frequent changes in body position or immediate changes in body position. Although the records support that a fixed height or variable height hospital bed is necessary, the records do not support that all of the criteria for a semi-electric hospital bed are met. Therefore, the services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in 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 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. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (31624) provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 31624 is "Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage". We asked our coder 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 services. Our reviewer says that the use of code 31624 is not supported by the records provided.
Our reviewer found that the medical records provided do not include sufficient documentation to validate that a "Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage", was performed on February 11, 2021. Therefore this service cannot be verified. We looked at this coder'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 pay for the services (31624) provided on February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra (J3490).
You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Xiidra (J3490).
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.