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

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve the requested services. You say that the enrollee has failed non-operative treatment. The Plan denied your request. The Plan says the procedure is considered unproven.  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 requested services. Our physician reviewer found that the Intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure. Therefore, the request is not considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the dental services provided on June 12, 2021 and June 16, 2021.  You asked the Plan to pay more for the dental services. You say that you've had dental cleanings in the past and have never had excessive charges. You say that you were provided a dentist that was in-network and you were overcharged. The Plan denied your request. The Plan says the claim was processed correctly.  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 is only obligated to pay the allowed amount for the dental services provided on June 12, 2021 and June 16, 2021. You are responsible for the full amount by which the actual charges of an out-of-network dentist exceed the allowable charge. Therefore, we decided that the Plan does not have to pay more for the dental services provided on June 12, 2021 and June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.         The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the biopsy of nail unit (11755-59) provided on June 1, 2021.  You asked the Plan to pay for the biopsy of nail unit. You say that the documentation supports the services as billed with the -59 modifier. The Plan denied your request. The Plan says the documentation provided does not indicate that the services were billed correctly.    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.  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 the biopsy of nail unit Our reviewer says that the documentation does not support the services as billed. Our physician reviewer found that modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury. In this case, the procedure report does not support the biopsy to meet criteria for distinct procedure from the incision and drainage, and removal of great toe.   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 biopsy of nail unit have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy of nail unit (11755-59) provided on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a travel continuous positive airway pressure (CPAP) device.  You asked the Plan to pre-approve the requested device. You say that you do not want to leave your CPAP at one house. The Plan denied your request. The Plan says a second device is not considered reasonable.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a CPAP device. Your current device serves the same purpose as the requested device. Therefore, we decided that the Plan does not have to pre-approve a travel continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve a scooter. You say that you need the scooter to go from your house to the car. The Plan denied your request. The Plan says the requested use is not covered.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The scooter at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fillings (D2335) for teeth #s 7 and 26 provided on May 26, 2021.  You asked the Plan to pay for the dental services. You say that you were not informed that this was only covered once every 48 months. You also say that you are trying to preserve your teeth and keep them healthy. The Plan denied your request. The Plan says there is a 25% coinsurance for fillings. The Plan says that fillings are covered once every 48 months per tooth. The Plan says that the frequency limit has been exceeded. The Plan also says that payment was made for fillings for teeth # 7 and 26 that you received on October 12, 2020.  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 and filling are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for fillings for teeth # 7 and 26 that you received on October 12, 2020. Therefore, we decided that the Plan does not have to pay for the fillings (D2335) for teeth #s 7 and 26 provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee is medically stable. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve neurosurgery services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are available in-network providers.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve neurosurgery services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the anesthesia for percutaneous image guided procedures on the spine and spinal cord  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on medical necessity of the services as billed. The Plan denied your request. The Plan says that the claim has denied correctly.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has failed to substantiate their denial for the rendered services. Specifically, the documentation does not include a reason for why the services have been denied. The decision letters that have been submitted are unclear on why the Plan has denied payment for these services. It is the burden of the Plan to substantiate their denial for services rendered. Therefore, we decided that the Plan has to pay for the anesthesia for percutaneous image guided procedures on the spine and spinal cord   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee is not on insulin 3 times a day.  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 does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services (64415-59) and anesthesia services (99100) provided on March 25, 2021.  You asked the Plan to pay for the medical services. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says the billed -59 modifier is not supported by the medical documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 the injection services. Our reviewer says that the medical documentation does not support the services as billed. Our physician reviewer found the submitted procedure report was difficult to read due to poor quality copy. However, an anesthetic injection agent was not found in documentation, and therefore cannot be confirmed as performed.  Regarding the anesthesia services coded as 99100, the Physician Fee Schedule indicates that this service has a Status Code of "B" which indicates this is a Bundled Code. This status code indicates that payment for covered services is always bundled into payment for other services not specified.  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 injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (64415-59) and anesthesia services (99100) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the fixed bridge to replace tooth #14.  You asked the Plan to pre-approve the fixed bridge. You say that the patient is not able to eat due to gaps. You say that the patient would greatly benefit from a bridge and it should be reconsidered. The Plan denied your request. The Plan says a bridge is not covered to replace a posterior tooth.  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, a bridge is only covered to replace anterior teeth. Tooth #14 is a posterior tooth. Therefore, we decided that the Plan does not have to pre-approve the fixed bridge to replace tooth #14.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an in-network exception for neurosurgery services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an in-network exception. You say that the in-network provider said he could not do the surgery. The Plan denied your request. The Plan says no in-network inadequacies are seen.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.   The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. You also have benefits that allow you to receive care from out-of-network providers. We found no exception that would require the Plan to pre-approve an in-network exception. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for neurosurgery services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on January 7, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that the laboratory services are not supported in the record. Specifically, the record indicates that the member was inpatient on the billed date of service. Payment for the technical component of this laboratory service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested device. You say that the enrollee is starting to experience significant hypoglycemia. The Plan denied your request. The Plan says the enrollee does not meet the criteria.  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 does not indicate that the enrollee uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. 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 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 Opdivo. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee metastatic Non-Small Cell Lung Cancer (NSCLC) (adenocarcinoma). the documentation shows that the enrollee has chosen to avoid chemotherapy. Computerized tomography (CT) evidence shows progressive disease after three cycles of Keytruda. The review indicates that the requested use of Opdivo is not FDA-approved for the enrollee's diagnosis. There is no compendia, guideline, or literature support found for use of a PD-L1 inhibitor following failure of a PD-L1 inhibitor in advanced NSCLC. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 6, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you are on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says you have been charged the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground trip. The enrollee has been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance Services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided by on February 6, 2020.