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

 We decided that the Plan does not have to pre-approve blepharoplasty and rhinoplasty.  You asked the Plan to pre-approve blepharoplasty and rhinoplasty. You say that the enrollee desires this surgery in order to complete her physical transition. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the Plan did not receive information such as doctor's notes or photographs so this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve blepharoplasty and rhinoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is a male to female transsexual. The record indicates that the enrollee has previously undergone surgery in 2017 but is not satisfied with those results. The record includes supporting letters but no primary source medical documentation to support the blepharoplasty or rhinoplasty.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blepharoplasty and rhinoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty and rhinoplasty.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home health aide, per hour (S9122).  You asked the Plan to pre-approve a home health aide. You say that a home health aide has been requested from the enrollee's primary care physician (PCP) since the beginning of the year. You say that the enrollee is very weak and cannot stand and help her own needs. You also say that the enrollee is homebound per last physician that went to a home consultation. The Plan denied your request. The Plan says the enrollee does not require skilled services.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says that the requested home health aide is not medically necessary. Our physician reviewer found the medical records provided do not indicate that the services meet the definition of home health aide services. The reviewer found that the records do not document that the enrollee is receiving any skilled nursing or therapy services. The reviewer also found that there is no documentation that the home health aide services meet Medicare criteria for reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. Therefore, the reviewer found that the requested home health aide is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home health aide have not been met. Specifically, the file does not indicate that the enrollee is receiving any skilled nursing or therapy services. Therefore, we decided that the Plan does not have to pre-approve a home health aide, per hour (S9122).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (80307) rendered by the out-of-network (OON) provider on January 5, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 services at issue in this appeal. 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 the office visit (99214) and the laboratory service (80307) rendered by the out-of-network (OON) provider on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (0012M) rendered by the out-of-network (OON) provider on July 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (0012M) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 76705) provided to the enrollee on August 8, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 76705) provided to the enrollee on August 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Pembrolizumab and Pemetrexed Disodium.  You asked the Plan to pre-approve Pembrolizumab and Pemetrexed Disodium. You say that the requested treatment is medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says use of a PDL -1 inhibitor is not recommended when disease progression has been seen with previous use. The Plan also says that the criteria for coverage has not been met.  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 Pembrolizumab and Pemetrexed Disodium. Our reviewer says that the requested regimen is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of lung cancer with metastases to the bone. The record indicates that the enrollee's disease has progressed while on a programmed death-ligand 1 (PDL-1) inhibitor. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The reviewer also found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested regimen is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab and Pemetrexed Disodium have not been met. Specifically, the file shows that the enrollee's disease has progressed while on a PDL-1 inhibitor. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab and Pemetrexed Disodium.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #30.  You asked the Plan to pre-approve core buildup. You say that you required replacement of a crown that fractured, and core buildup is a necessary procedure. You say that the predetermination that core build is not covered is unacceptable and the claim should be approved. 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 core buildup (D2950) for tooth #30.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from May 20, 2021, through June 18, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says continuation of SNF services 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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF.  By the dates in question, the enrollee was at a moderate assist level for transfers. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from May 20, 2021, through June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care as of December 22, 2021.  You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing this decision. The Plan denied your request. The Plan says the denial of authorization for inpatient psychiatric care is correct, because you do not require treatment at this level of care and can be treated at a lower level such as partial hospitalization program.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care. Our reviewer says that you do not meet the Medicare criteria for inpatient psychiatric care as of December 22, 2021. Our physician reviewer found it is not expected that you would improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any symptoms which would require acute treatment. It does 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.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care as of December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).  You asked the Plan to pre-approve the ablation procedure. You say that the ablation procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and non-covered.  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 ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental. More research is needed to show safety and efficacy.  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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on April 19, 2021.  You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 for the computed tomography is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70450 provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on July 19, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on July 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for your condition. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 you are a 75-year-old female with a fall and urinary tract infection. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest, abdomen and pelvis.  You asked the Plan to pre-approve a CT scan. You say that this imaging service is medically necessary due to your weight loss. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the requested CT scan of the chest is not medically reasonable and necessary. Our physician reviewer found you have proteinuria, renal insufficiency, and evidence of stone-associated right hydroureter. In addition, you have a 4-pound weight loss over 5 weeks is documented in the period October 4, 2021, to November 8, 2021. However, neither a chest X-ray nor equivocal abdominal ultrasound was provided. In addition, you have not undergone endoscopic evaluation for over 7 years. As a result, the CT scan services will be considered premature at this time and not medically reasonable and 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 a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest, abdomen and pelvis.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).  You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee meets inclusion criteria for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is a lack of evidence showing that Vertiflex is as safe and effective as the gold standard of decompression.  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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on July 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 2, 2021, by an out-of-network (OON) provider.