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

We decided that the Plan has to pay for the extracorporeal photopheresis (36522) provided on August 20, 2021.
You asked the Plan to pay for the extracorporeal photopheresis. You say that the extracorporeal photopheresis provided on August 20, 2021 was medically necessary. The Plan denied your request. The Plan says that the enrollee did not meet criteria for the extracorporeal photopheresis provided on August 20, 2021.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the extracorporeal photopheresis. Our reviewer says that the enrollee met criteria for the extracorporeal photopheresis provided on August 20, 2021.
Our physician reviewer found bronchiolitis obliterans (BOS) is a rare disorder without clear guidelines for treatment. This enrollee has progressive BOS from Castleman's. Single center experiences have shown effectiveness and among 51 patients with BOS treated with ECP (two successive days every two weeks for three months and then every four weeks), the FEV1 improved or stabilized in 61 percent. The service was reasonable and 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 the extracorporeal photopheresis have been met. Therefore, we decided that the Plan has to pay for the extracorporeal photopheresis (36522) provided on August 20, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for disposable supplies (E1399).
You asked the Plan to pay for the supplies. You say that this should be covered based on medical necessity. The Plan denied your request. The Plan says Medicare states that for disposable supplies, supply Healthcare Common Procedure Coding System (HCPCS) codes must be used.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that procedure code E1399 is not supported in the medical record. Specifically, disposable supplies should be reported with a CPT code. HCPCS codes should be used. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for disposable supplies (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig, any type.
You asked the Plan to pre-approve the wig. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 a wig, any type.
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 monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the enrollee does not use insulin with at least three daily injections, require 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a provisional crown (D2799x2), a prefabricated post and core in addition to crown (D2954x2), a pontic, porcelain/ceramic crown (D6245x2) and a retainer crown (D6740x2).
You asked the Plan to pre-approve a provisional crown, a prefabricated post and core, a pontic, porcelain/ceramic crown and a retainer crown. You say that you are unable to eat correctly and only little by little. You had a bridge on your teeth for 38 years. You also say that you do not have money, or a savings account and you are unable to eat without getting this dental work done. The Plan denied your request. The Plan says the requested services are not covered benefits with 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. Therefore, we decided that the Plan does not have to pre-approve a provisional crown (D2799x2), a prefabricated post and core in addition to crown (D2954x2), a pontic, porcelain/ceramic crown (D6245x2) and a retainer crown (D6740x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).

You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that you are in
extreme pain and the doctor who requested this knows you need this treatment. The Plan denied your request.
The Plan says the service 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 insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that interlaminar spacer devices are 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 insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, Carboplatin, and Dexamethasone Sodium Phosphate.
You asked the Plan to pre-approve Keytruda, Pemetrexed, Carboplatin, and Dexamethasone Sodium Phosphate. You say that the medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Keytruda, Pemetrexed, Carboplatin, and Dexamethasone Sodium Phosphate. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the enrollee has progressed on maintenance pemetrexed and within 6 months of treatment of pembrolizumab. Retreatment with the same regimen is not indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Pemetrexed, Carboplatin, and Dexamethasone Sodium Phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Pemetrexed, Carboplatin, and Dexamethasone Sodium Phosphate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) 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 there is no urgent or emergent medical condition.

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 at a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate. Based on the medical records provided there is inadequate documentation that the enrollee has failed a four week trial of conservative therapy. 

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 a pneumatic compression device (E0651, E0667) for the enrollee.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 is improving and still requires acute care services. The records do not support the LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on September 9, 2021.
You asked the Plan to pay for the cleaning. You say that your provider told you that you needed to have a cleaning every four months. The Plan denied your request. The Plan says you have already had two adult prophylaxis cleanings earlier in the year. This service is only covered twice per year, and the third instance provided on the date in question exceeds your benefit limitations.
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 can cover standard adult dental cleanings (D1110) up to two times per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning is requested in a frequency that exceeds what is covered under this benefit. Documentation supports that the Plan has already paid for two prior dental cleanings (D1110) in the 2021 plan year. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466).

You asked the Plan to pre-approve continued use of a home ventilator. You say that the ventilator remains
medically necessary. The Plan denied your request. The Plan says ongoing coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 continued use of a home ventilator. Our
reviewer says that ongoing use of the ventilator is not medically necessary. Our physician reviewer found based
on the latest medical records provided there is no documentation that supports that the ventilator at issue is
medically necessary and reasonable for this patient as records continue to document inadequate adherence to
use of the 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 continued use of a home ventilator have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been
exhausted. Therefore, coverage criteria have not been met.
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 36 one-way transportation trips when each one-way trip does not exceed 50 miles.
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 mileage.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for therapeutic interventional radiological procedures involving the arterial system (01926) provided on July 30, 2021.
You asked the Plan to pay for the anesthesia service. You say that the enrollee was not eligible for hospice for this procedure and 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. 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 the anesthesia for therapeutic interventional radiological procedures involving the arterial system (01926) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a new patient office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 new patient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for chest x-ray services provided on September 23, 2021.

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

The file shows that CPT code 71045 was billed along with 71046. We find that CPT code 71045 may be
eligible for payment when billed with this code pair. The claim information does not show that CPT code
71045 was not billed with a modifier suitable for payment. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for chest x-ray services provided on September 23, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the lower extremity.

You asked the Plan to pre-approve a CT scan of the lower extremity. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the lower extremity. Our reviewer says that the services are medically necessary. Our physician reviewer found the surgical technique for robotic assisted total knee arthroplasty is enhanced with a pre-operative CT of the knee for the purposes of operative planning, in particular the type of prosthesis. The surgeon needs this information to optimize patient care and the request should 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 a CT scan of the lower extremity have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the lower extremity.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling for tooth # 21 provided on September 15, 2021.
You asked the Plan to pay for the dental service. You say that being charged for the third filling is ridiculous. You say that you were not aware that only 2 of these would be covered. You also say that this should be covered. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid the in network rate for fillings for tooth # 3 received on September 15, 2021, and for tooth # 15 received on September 1, 2021. Therefore, we decided that the Plan does not have to pay for the filling for tooth # 21 provided on September 15, 2021.