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

We decided that the Plan does not have to pre-approve the transurethral destruction of prostate tissue; by
radiofrequency generated water vapor thermotherapy (CPT code 53854), for the enrollee.
You asked the Plan to pre-approve the service. You say that a pelvic ultrasound was performed, and the
enrollee had a 35cc prostate. You state the enrollee has tried Flomax in the past for three (3) weeks but had an
adverse reaction to the medication and was advised to stop. You state that you believe this is the best treatment
for the enrollee. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.
Specifically, the following criteria have not been met:
1. Failure, contraindication or intolerance to at least three months of conventional medical therapy for BPH
(e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
2. Poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease,
pulmonary disease, etc.), or at high risk of bleeding
3. Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc).
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the transurethral destruction of prostate tissue; by radiofrequency generated water vapor
thermotherapy (CPT code 53854), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous laminotomy/laminectomy (interlaminar
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy,
facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single
or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T), for the enrollee.
You asked the Plan to pay for the service. You say that the service is necessary. The Plan denied your request.
The Plan says they do not meet the requirements. The Plan states the requirement is that the enrollee is enrolled
in an approved clinical study for lumbar spinal stenosis. The Plan must follow Medicare rules. We looked at
the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the
service have not been met. There is no documentation provided to support the enrollee is participating in an
approved clinical study for evidence development. Therefore, we decided that the Plan does not have to pay for
percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or
without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect
image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT code
0275T), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crowns (D2740) provided on June 17, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay more for the crowns. You say that according to your best knowledge you settled
your dental account with this provider. You also say that you were not advised there was any pending liability.
The Plan denied your request. The Plan says your benefit maximum has been reached. The Plan also says that
these services were 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,500 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit while processing this claim for the June 17, 2021 date of service and your annual maximum
benefit has been exhausted. You are also responsible for the difference between the billed amounts and allowed
amounts because these services were received OON. Therefore, we decided that the Plan does not have to pay
more for the crowns (D2740) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Apex Medical Sedens 500 Alternate Pressure Seat Cushion with Portable Pump (18"x18") (E1399).
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your request. The Plan says the effectiveness of a powered seat cushion (E2610) has not been established.
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 cushion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested seat cushion with portable pump exceeds the enrollee's medical needs and is not proven to be more effective for the prevention or treatment of the enrollee's recurrent sacral ulcers than other standard seat cushions for this condition.
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 cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve the Apex Medical Sedens 500 Alternate Pressure Seat Cushion with Portable Pump (18"x18") (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921 x 4) and take home drugs (D9630 x 2) provided on August 10, 2021.  You asked the Plan to pay for the dental services. You say that there are some situations where dental benefits that you feel the work performed falls within the guidelines for the services rendered. You say that one is the length of time between visits. You also say that the other is the pain you are having from decay of bone loss. The Plan denied your request. The Plan says the scaling in presence of generalized moderate or severe gingival inflammation is not listed as a covered service. The Plan says gingival irrigation is not listed as a covered service. The Plan also says take home drugs are not listed as covered services either.  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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921 x 4) and take home drugs (D9630 x 2) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on July 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. 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 a covered benefit.  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 drug testing provided on July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided by an opted out physician on September 2, 2021.  You asked the Plan to pay for office visit. You say that you have exhausted every option with regular Plan network doctors. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider has opted out of Medicare coverage and is not covered.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided by an opted out physician on September 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extension of home care services, including skilled
nursing and physical therapy.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's
condition and/or prevent deterioration. There is no evidence of complex wound care, IV medications, new
enteral feedings or other SNF need. The enrollee is able to administer her own insulin. There are no recent
medication or treatment changes. The records do not show that skilled therapy services are required to
effectively provide treatment, care, and/or services in order to improve your level of function, or to
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. You
have been educated in a home exercise program and does not require the ongoing professional skills of physical
or occupational 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 extension of home care services, including skilled nursing and physical therapy
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary. The
Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Keytruda. Our reviewer says that the
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer
found the enrollee is a 69-year-old male diagnosed with penile cancer squamous cell carcinoma that is now
metastatic. In this case, the requested drug is not FDA-approved for the enrollee's condition. However, the use
of Keytruda is supported by one of the major drug compendia or by clinical research that appears in a
Medicare-approved medical journal. Penile cancers are often treated similar to cervical cancers given
association with human papillomavirus. They usually express PD-L1 due to the rarity of the cancer. This
patient's tumor has a PD-L1 of 10. Although there is only limited data to support use of Keytruda, there is
support for the requested drug.
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 have been met. Therefore, we decided that the Plan has to pre-approve
Keytruda.
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: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a knee arthroscopy.  You asked the Plan to pre-approve a knee arthroscopy. You say that the requested surgical services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met for the requested surgery.  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 pre-approve a knee arthroscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 73-year-old male being treated for pain in the left knee; unilateral post-traumatic osteoarthritis, left knee. He presents with left knee pain for 4-5 months after working on his deck. He localizes the pain to the medial joint line. The knee feels very heavy as though "feels like it's getting hit by a hammer." He also reports mechanical symptoms with catching and instability. He occasionally feels like the left knee will give out. Exam reveals antalgic gait. Range of motion is -3 degrees of extension, no deformity. There are large-scale, long-term references showing the safety and relative efficacy of the requested surgery in the setting of mild medial or lateral compartment arthritis/degenerative changes. Additionally, there is significant evidence of increased pain, mechanical catching and instability, along with positive signs of meniscal/cartilagenous joint pathology. In conclusion, there is compelling rationale/extenuating circumstances noted to support the medical necessity of this request as a relative exception, due to the evidence provided. Therefore, the request for knee arthroscopy with meniscectomy (medial and lateral including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s) when performed is medically reasonable and 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 a knee arthroscopy have been met. Therefore, we decided that the Plan has to pre-approve a knee arthroscopy.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on March 17, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
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, we have confirmed that code 70544
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 4, 2021, to February 5, 2021.
You asked the Plan to pay for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. The Plan says that the facility name is not Medicare certified as no active CMS Certification Number (CCN) is on file from this provider. The Plan also says that the claim was processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 4, 2021, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the epidural steroid injections.
You asked the Plan to pre-approve the epidural steroid injections. You say that this is medically reasonable and
necessary. The Plan denied your request. The Plan says the records do not show that your pain failed to
improve after a four-week trial of standard treatment methods.
The Plan must follow Medicare rules. Medicare rules say that you must have had at least 4 weeks of
conservative noninvasive care that is also performed in conjunction with the ESIs.
We looked at the file and Medicare rules. In this case, the documentation states that physical therapy is not
being performed and the recommendation at this time is for physical therapy to begin. There is no evidence that
the 4-week conservative trial required has been completed. Based on this information, we decided that
Medicare rules for coverage of the epidural steroid injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve the epidural steroid injections
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0480) provided on September 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.  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 drug testing (G0480) provided on September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 7 additional physical therapy (PT) visits.  You asked the Plan to pre-approve 7 additional PT visits. You say that the enrollee needs these services. The Plan denied your request. The Plan says the additional PT visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 7 additional PT visits. Our reviewer says that the additional 7 PT visits are not medically necessary. Our physician reviewer found that the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The reviewer found that the enrollee is at a high functional level in physical therapy. The reviewer found that the enrollee has had prior therapy and has been educated in a home exercise program. Therefore, the reviewer found that the enrollee does not additional skilled physical therapy visits.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 additional PT visits have not been met. Specifically, the file does not indicate that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Therefore, we decided that the Plan does not have to pre-approve 7 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 20 provided on September 15, 2021.  You asked the Plan to pay for the dental service. You say that you were not informed what was being done. You say that you were not informed of the charges. You also say that you chose this plan because you thought it would cover the dental work you needed. The Plan denied your request. The Plan says core build up 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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth # 20 provided on September 15, 2021.