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

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on January 20, 2021.  You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The Plan denied your request. The Plan says the laboratory services billed by the provider are not payable under the definition of "physician services.  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 laboratory service have not been met. Review of the file shows that the enrollee was inpatient at the hospital during the date of service. The rules say that the applicable payments made under the prospective payment systems are payment in full for all facility or hospital services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR Section (409.3). Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.  You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that you do not meet criteria for coverage.  The Plan must follow Medicare rules. Medicare rules say that a group 2 support surface is covered if LCD criteria 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 powered pressure-reducing air mattress. Our reviewer says that a powered pressure-reducing air mattress is not considered medically reasonable and necessary in this case. Records do not document that you have multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over the past month or that you have large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or that you have had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. Our physician reviewer found that your condition does not meet Medicare criteria for a powered pressure-reducing air mattress.  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 powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an L300 Go Lower system (E0770, electrical stimulator).  You asked the Plan to pre-approve an L300 Go Lower system. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.  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 an L300 Go Lower system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that you had a stroke that resulted in right foot drop. You wear an ankle foot orthosis (AFO) to address the foot drop. There is no evidence that your medical needs cannot be met by the AFO. There is not enough evidence from the provider that states how you would benefit from the requested device.  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 L300 Go Lower system have not been met. Therefore, we decided that the Plan does not have to pre-approve an L300 Go Lower system (E0770, electrical stimulator).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for contact lens fitting provided on August 18, 2021.  You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says contact lens fitting is not a covered benefit.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    We looked at the file and the Plan's rules. The file shows that the Plan does not cover contact lens fitting. Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors  You asked the Plan to pre-approve Freestyle Libre 2 sensors. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.  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 perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367), drugs or medicaments dispensed in the office for home use (D9630), and surgical placement of implant body: endosteal implant (D6010) provided August 24, 2021.  You asked the Plan to provide additional payment for the cone beam CT scan, endosteal implant and other drugs and/or medicaments. You say that you would like these services covered. The Plan denied your request. The Plan says you have exceeded your dental maximum for 2021 and are responsible for the remaining costs.  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 supplemental preventative and comprehensive dental services up to a $1,500 combined dental allowance.   We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim was processed you had $424 remaining in your dental allowance. This amount was applied to your claims. You are responsible for the remaining cost. Therefore, we decided that the Plan does not have to provide additional payment for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367), drugs or medicaments dispensed in the office for home use (D9630), and surgical placement of implant body: endosteal implant (D6010) provided August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a neurology consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a neurology consultation. You say that you have seen 4-5 in network neurology providers and they are all horrible. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a neurology consultation to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF services to be provided by the out-of-network facility at the in-network benefit coverage level.  
You asked the Plan to pre-approve SNF services to be provided by the out-of-network facility at the in-network benefit coverage level. The Plan denied your request. The Plan says that the Plan will approve (11) days skilled nursing admission the requested facility to pay at the out-of-network benefit level under authorization number 220103024578. The SNF services have been approved from December 31, 2021, to January 10, 2022.  
The contract with the Plan says as a member of our Plan, you (the enrollee) can receive your care from either a network provider or an out-of-network provider. If you (the enrollee) use an out-of-network provider, your share of the costs for your covered services may be higher.  We looked at the file and the Plan's rules. The file shows that the Plan contract provides a benefit for care from either a network provider or an out-of-network provider. If the enrollee uses an out-of-network provider, the enrollee's share of the costs for covered services may be higher. The file shows that Plan has approved SNF services to be provided by the requested facility from December 31, 2021, through January 10, 2022 at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve SNF services to be provided by the requested facility at the in-network benefit coverage level.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits.  You asked the Plan to pre-approve home health services. You say that home health care is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found you are a 43-year-old female with a history of osteoarthritis and total hip replacement in 2017. Based on the documentation provided, you do not have documented, ongoing, home health physical therapy (HH PT) needs. You are currently functioning at a level commiserate with a lower level of care. As such, the requested, ongoing, HH PT is not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits.
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 a semi electric hospital bed. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is 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 a semi electric hospital bed. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of multiple sclerosis. There is no documentation that the patient requires frequent changes in body position or immediate changes in body position. Therefore, the enrollee does not meet criteria for the requested item.  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 semi electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve Magnetic resonance cholangiopancreatography (MRCP).  You asked the Plan to pre-approve the MRCP. You say that the records provided support the need for the requested MRCP. The Plan denied your request. The Plan says that the requested study is not the appropriate initial imaging modality for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. An MRCP is a type of MRI.  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 MRCP. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the clinical question is whether there is biliary, pancreatic duct obstruction by mass or stone. Stone is in the differential due to the history of multiple small gallstones seen on previous ultrasound while pancreatic mass is considered due to lack of significant elevation of liver enzymes. The question of gallstone pancreatitis and or pancreatic mass at the Ampulla of Vater are reasonable questions. Ultrasound would not be sufficient to look for pancreatic head or Ampullary masses and MRCP would be the best available technique to do so.  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 MRCP have been met. Therefore, we decided that the Plan has to pre-approve Magnetic resonance cholangiopancreatography (MRCP).   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 the pneumatic compression device (CPT code E0676).  You asked the Plan to pre-approve a pneumatic compression device. You say that this is to be used while getting a knee replacement. The Plan denied your request. The Plan says the medical record from the provider shows that this item was requested for use at home following a right knee replacement surgery on November 9, 2021, and you are requesting the same device for your left knee replacement surgery which is scheduled for January 18, 2022. The Plan states your request is not medically necessary because your records show that the service was requested to prevent blood clots after your knee replacement surgery and are excluded from coverage under the Medicare durable medical equipment (DME) benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.   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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (CPT code E0676).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Procrit.  You asked the Plan to pre-approve Procrit. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 Procrit. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee is on chemotherapy and is requesting Procrit for chemotherapy-induced anemia. In this case, lab values are not included in the case documentation. Without these lab values, it is unclear at this time if the criteria for coverage listed in the Medicare rules section have been satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  The Plan must follow Medicare rules. The rules say that 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on March 10, 2021.  You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and panoramic x-ray. You say that you did not know that your dental allowance had been used up. You also say that these services were rendered in March and should have been covered. The Plan denied your request. The Plan says your 2021 calendar year maximum had been met.  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 Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit on July 7, 2021, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 17, 2021.  You asked the Plan to pay for the surgical extraction. You say that you were not aware that you did not have coverage for surgical extractions. The Plan denied your request. The Plan says this service is not covered under your plan.  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 only type of extractions that are covered under your plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Stelara infusions (J3358).  You asked the Plan to pre-approve Stelara infusions. You say that the requested drug is medically necessary for the enrollee's treatment. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 Stelara infusions (J3358).   Benefits for Stelara infusions may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.