Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.

You asked the Plan to pre-approve upgraded electronics or gel footplate covers. You say that this power wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, the upgraded electronics and gel footplate covers are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover equipment for convenience. The requested upgraded electronics and gel footplates are added convenience items that are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration services.
You asked the Plan to pre-approve bone marrow aspiration services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that this is helpful for the enrollee's problems.
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 bone marrow aspiration services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use as bone graft material in spinal surgery. More research is needed before this procedure will be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery for removal of tunneled intraperitoneal catheter (49422) provided April 14, 2021.
You asked the Plan to pay for assistant at surgery for removal of tunneled intraperitoneal catheter. You say that payment should be made based on medical necessity for the surgical assistant. The Plan denied your request. The Plan says based on Medicare rules, an assistant at-surgery for the procedure billed is not payable.
The Plan must follow Medicare rules. Medicare rules say that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. We looked at the file and Medicare rules. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 49422. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based on this information, we decided that Medicare rules for coverage of
assistant at surgery for removal of tunneled intraperitoneal catheter have not been met. Therefore, we decided
that the Plan does not have to pay for assistant at surgery for removal of tunneled intraperitoneal catheter
(49422) provided April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery services provided on April 8, 2021 by an out-of-network provider.
You asked the Plan to pay for transluminal balloon angioplasty (36907), introduction of catheter, dialysis circuit, (36901) and moderate sedation services (99152). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 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 outpatient surgery services provided on April 8, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and intraoral - periapical first radiographic image (D0220) provided February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the crown and intraoral x-rays. You say that you called the Plan's customer service prior to receiving the necessary services and were told that after you paid the bill you would be reimbursed $1,000. The Plan denied your request. The Plan says their records do not show any calls to the Plan about coverage prior to the service and there is no coverage for dental services when rendered by an OON provider.
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 crown and intraoral x-rays when the services are provided in-network. We looked at the file and Medicare rules. The requested provider in this case is not a network dental 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. Based on this information, we decided that the Plan's rules for coverage of the crown and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and intraoral - periapical first radiographic image (D0220) provided February 15, 2021 by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded
99239 provided on February 1, 2020.
You asked the Plan to pay for the hospital discharge day management services. 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
supported by the 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.
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge
summary does not support hospital discharge day management of more than 30 minutes was performed. A
documented duration of time of 31 minutes or more is required to support this code. Based on this information,
we decided that Medicare rules for coverage of the hospital discharge day management services have not been
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management
services coded 99239 provided on February 1, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve daratumumab.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found daratumumab is not FDA approved as monotherapy unless the enrollee has received at least three prior lines of therapy. Use as monotherapy as second line therapy is not supported by the National Comprehensive Cancer Network (NCCN) guidelines, major drug compendia, or the medical literature. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve daratumumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and supplies.
You asked the Plan to pre-approve a CPAP device and supplies. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a CPAP device and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the Continuous Positive Airway Pressure device and supplies at issue in this case meet Medicare Criteria for medically reasonable and necessary as the records do not include a valid Detailed Written Order, Physician's Certification or sleep study test results. 
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 CPAP device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 7, 2021.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PBRT.

You asked the Plan to pre-approve PBRT. You say that you would like reconsideration because this is a medically necessary, Medicare covered treatment. The Plan denied your request. The Plan says PBRT is not the standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.

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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more beneficial than Intensity-Modulated Radiation Therapy (IMRT)/Image Guided Radiation Therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve PBRT.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network elective surgery services for the enrollee.
You asked the Plan to pre-approve out of network services. You say that this care is medically necessary. The Plan denied your request. The Plan says this care can be provided in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. You are 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 out of network elective surgery services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a device for intrathecal or epidural drug
infusion for the enrollee.
You asked the Plan to pre-approve the implantation. You say that the enrollee is experiencing neuropathy
bilaterally to lower extremities. The Plan denied your request. The Plan says 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 the implantation. Our reviewer says that
the requested implantation is not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no specific clinical rationale for the requested implantation of a device. The enrollee
has responded to opioids which can be given in other modalities prior to consideration of an intrathecal pump.
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 implantation have not been met. Therefore, we decided that the Plan does
not have to pre-approve implantation of a device for intrathecal or epidural drug infusion for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve lumbar ESI. You say that you received a previous injection which resulted
in much less pain. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because the Plan approved 1 epidural and the response to each epidural should be determined prior to
determining the value of repeat epidural and the specific methods used for subsequent epidurals.
The Plan follows Medicare rules. Medicare rules state that the response to each epidural should be determined
prior to determining the value of a repeat epidural and the specific methods used for subsequent epidurals.
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 lumbar ESI. Our reviewer says that you
do not meet the Medicare criteria for the requested epidural. Our physician reviewer found the response to each
epidural should be determined prior to determining the value of a repeat epidural and the specific methods used
for subsequent epidurals. There is no specific clinical rationale for a second epidural steroid injection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of lumbar ESI have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration 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 the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.

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. Bone marrow
aspiration remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate
when used as bone graft material. 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 bone marrow aspiration for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on May 11, 2021.
You asked the Plan to pay for the consultation. You say that you were advised by a plan representative that this provider was in network. You say that you were advised that your regular periodontist no longer accepted your insurance. You also say that you have been receiving periodontal cleanings every 3 months for over 20 years. The Plan denied your request. The Plan says consultation is not listed as a covered service.
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 consultation is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye exam (92014) provided on September 25,
2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the medical eye exam. You say that you would like this claim reprocessed and
approved for payment as you were unaware they were OON. The Plan denied your request. The Plan says prior
authorization was not obtained for these services rendered by an OON 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 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.
Therefore, we decided that the Plan does not have to pay for the medical eye exam (92014) provided on
September 25, 2020, by an out-of-network (OON) provider.