Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) seat elevator (E2300) and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve the seat lift and upgraded electronics. You say that please reconsider the documentation provided for the wheelchair and accessories that are medically necessary to meet the client's current needs. The Plan denied your request. The Plan says the seat elevator does not service a primary medical purpose and although there are 3 approved power options, there is no medical need to control these power options through the joystick.
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 seat lift and upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records, however, did not sufficiently support these accessories as leading to medical improvement but rather to increase independence. There was no indication other means of transfers would not be medically reasonable for the enrollee. Therefore, these records do not meet the Medicare criteria for the requested accessories. 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 seat lift and upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) seat elevator (E2300) and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on April 27, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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. Therefore, we decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the osseous surgery for tooth #'s 6 to 8.
You asked the Plan to pre-approve the osseous surgery. You say that the patient had osseous surgery in the
upper right in 2017 and the pockets were root planed. You say that the decision should be reconsidered. The
Plan denied your request. The Plan says that there is no history of periodontal scaling or root planing.
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 osseous
surgery 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 osseous surgery. Our physician
reviewer found that there are defective crowns on tooth #'s 6-8 and recurrent marginal caries which require
more marginal tooth structure to properly be restored. Our reviewer says that this can be established by crown
elongation where there is adequate root length and adequate bone support. Our reviewer says that this service is
medically reasonable and necessary 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 the osseous surgery have not been met. Therefore, we decided that the Plan has
to pre-approve the osseous surgery for tooth #'s 6 to 8.
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 special casting material (A4590).
You asked the Plan to pre-approve the special casting material. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the special casting material (A4590).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing rendered on April 7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the CxBladder testing rendered on April 7, 2021.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the diagnostic service. We decided that the Plan does not have to
pre-approve computed tomography, lumbar spine (72131).
You asked the Plan to pre-approve the diagnostic service. You say that say the medical records provided
support the necessity of the services in dispute. The Plan says that there is insufficient evidence that the
requested service is reasonable and necessary. Given the absence of clinical documentation, medical necessity
has not been established.
We decided that the Plan has to pre-approve computed tomography, head or brain (70450) .
We also decided that the Plan does not have to pre-approve computed tomography, lumbar spine
(72131).
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 the diagnostic service. Our reviewer
says that the enrollee partially meets the criteria for the requested services. Our physician reviewer found the
enrollee with hypercalcemia malignancy, transformed large cell lymphoma and a history of breast cancer. The
records reflect vertigo. The provided records support approval of the CT head with diagnosis of vertigo and
history of lymphoma but supports denial of the CT of spine as there is no clinical indication.
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 diagnostic service have been met. Therefore, we decided that the Plan has to
pre-approve computed tomography, head or brain (70450) and does not have to pre-approve computed
tomography, lumbar spine (72131) .
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on February 26, 2021.

You asked the Plan to pay for the crown. You say that you would like to be refunded for this service. The Plan denied your request. The Plan says this procedure is not covered under your dental 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. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that there are no medical reasons that prevent the enrollee from using a
preferred drug.
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 Evenity. Our reviewer says that Evenity
is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Forteo and Tymlos
before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs.
There is no documentation provided indicating that the Plan's required drugs would likely be less effective
and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition
does not meet step therapy criteria for Evenity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that you would
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are
neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available
to you that can provide the services you are requesting.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
office visits to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation (AIR) admission and 
services. 
 
You asked the Plan to pre-approve AIR care. You say that the admission is medically necessary. The Plan 
denied your request. The Plan says the care can be rendered at a lower level. 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 AIR care. Our reviewer says that the 
requested acute inpatient rehabilitation (AIR) care is not considered medically reasonable and necessary based 
on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The reviewer found that your medical problems are stable and there are no complex nursing 
or rehabilitation needs. The reviewer found that you do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. The reviewer also found that there is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an AIR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of AIR care have not been met. Specifically, the file shows there is no documented 
need for a intensive, multi-disciplinary rehabilitation program. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation (AIR) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on July 12, 2020.

You asked the Plan to pay for the inpatient hospital care provided on July 12, 2020. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided on July 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021.
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 9, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (93312-59) provided on April 15, 2021.
You asked the Plan to pay for echocardiography. You say that this is supported. The Plan denied your request.
The Plan says this cannot be paid separately.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Specifically, the records do not show that this was a different session or patient encounter, different
procedure or surgery, different site, or organ system, separate incision/excision, or separate injury from code
00562, with which 93312 has a bundled relationship. Based on this information, we decided that Medicare
rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan
does not have to pay for echocardiography (93312-59) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigation 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 medical studies haven't proven that the computer-assisted surgical navigation is helpful for total joint replacement.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found computer-assisted surgery remains experimental. There is no research that shows it is better than conventional open surgery without computer use. More research is needed. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve computer-assisted musculoskeletal surgical navigation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631) provided on October 16, 2020.
You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631) provided on October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a procedure to remove excess abdominal skin (panniculectomy) (15830) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show a panniculus that hangs below the level of the symphysis pubis or that the enrollee's pannus is infected.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The record indicates that the enrollee is morbidly obese. The records contain a pulmonary clearance as the enrollee has had a right sided pleural effusion. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
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 procedure to remove excess abdominal skin (panniculectomy) (15830) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous laser ablation therapy 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 the records do not show any trouble functioning from symptoms. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not include an assessment that incorporates the data with respect to the patient 
complaints and results of the duplex evaluation with formulation of a cohesive plan. The last documentation 
recommends use of compression stockings and to obtain a duplex ultrasound. Other than that, there does not 
appear to be any plan for endovenous ablation articulated in the medical records. There is no documentation as 
to the location and nature of symptoms and what territory requires ablation. There is no documentation of a 
review of the findings with the enrollee with a discussion of the risks and options, and the enrollee's decision to 
proceed. In the absence of a cohesive plan that is patient and symptom directed, the request cannot be 
considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous laser ablation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablet 4mg.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no pharmacy benefit with the plan.

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 Ondansetron tablet 4mg.