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

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet radiofrequency ablation.

You asked the Plan to pre-approve the facet radiofrequency ablation. You say that you would like reconsideration because the member has had 90-95% relief with the previous left and right C6-T1 radiofrequency ablations. The Plan denied your request. The Plan says the member has exhausted their two sessions per spinal region within 12 rolling months.

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 facet radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had radiofrequency ablation C3-T1 two times within the year. The guidelines allow only two in a 12 month period.

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 facet radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Freestyle libre sensor refill (K0553), provided on April 10, 2021.

You asked the Plan to pay for the Freestyle libre sensor refill. You say that the item should be covered. The Plan denied your request. The Plan says they have contacted the member and found that the provider is cold calling the member and that member is receiving devices but not ordering them.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the Freestyle libre sensor refill have not been met. Therefore, we decided that the Plan does not have to pay for the Freestyle libre sensor refill (K0553), provided on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the duplex scan. You say that the enrollee was referred for access placement. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on May 10, 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 a shower chair.
You asked the Plan to pre-approve a shower chair. You say that when you stand to bathe you get dizzy and fall. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that orthotics is to correct your issue and if this do not work, you will need surgery. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 14, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).

You asked the Plan to pre-approve a chest CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had an x-ray or an ultrasound.

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 chest CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee was found to have a 1.2-centimeter cavitary nodule in the right upper lobe in 2010 and declined bronchoscopy at that time. The lesion was not hypermetabolic on a positron emission tomography (PET) scan and was unchanged on repeat CT scans in 2011 and 2012. The lesion was not visible on a chest x-ray in 2019. This lesion was previously demonstrated to be stable for more than 2 years. The enrollee is asymptomatic. There is no medical indication for further imaging of this lesion. 

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 chest CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) abdomen and pelvis (74177) and computed tomography (CT) thorax (71260).

You asked the Plan to pre-approve the CT scans. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested CT scans are premature and are not medically necessary at this time.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scans. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee complains of shortness of breath and diarrhea. The records did not show the results of a chest x-ray or the results of a thorough workup that failed to reveal the cause of the enrollee's weight loss (including blood tests that include hormone levels, a cope and/or barium swallow test), tests for blood in stool, or a detailed exam of the nervous system). The CT scans were ordered due to his weight loss and smoking history. The medical records provided do not meet the requirements for Medicare coverage. 

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 CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) abdomen and pelvis (74177) and computed tomography (CT) thorax (71260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 12, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the treatment has not been proven effective.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.
The file shows the enrollee received a urinary tract infection panel. We looked at the file and the rules. In this case, there are insufficient records to show that the results of testing will impact clinical management to improve the enrollee's outcome. 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 pay for the lab services provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 14, 2021.
You asked the Plan to pay for the dental service. You say that you reside in 2 different states for 6 months each year. You say that you needed to establish care with 2 different dentists this year. You say that this is a one-time occurrence. You also say that this should be covered as a one-time exception. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. 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 the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on August 11, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 14, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the myocardial perfusion imaging procedure (78452).

You asked the Plan to pre-approve the myocardial perfusion imaging procedure. You say that this imaging
service is medically necessary. The Plan denied your request. The Plan says that they did not receive a physical
exam with results and a detailed history that show a reason this study is needed.

The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms,
including otherwise unexplained angina equivalent symptoms and a history of coronary artery disease based on
a prior anatomic evaluation of the coronary arteries or physical inability to perform a maximum exercise
workload.

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 myocardial perfusion imaging
procedure. Our reviewer says that the requested service is medically reasonable and necessary for the enrollee's
condition. Our physician reviewer found that the record indicates that the enrollee was evaluated for shortness
of breath upon walking up one flight of stairs. The record indicates that the enrollee is deconditioned. The
record indicates that the enrollee has atherosclerotic heart disease. The record indicates that the enrollee has
known multivessel disease from a cardiac catherization in 2016, including a complete occlusion of a
nondominant right coronary artery. The elements of the coverage determination are satisfied in this case.

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 myocardial perfusion imaging procedure have been met. Therefore, we
decided that the Plan has to pre-approve the myocardial perfusion imaging procedure (78452).
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 pre-approve diagnostic facet joint injections (64493, 64494, 64495).

You asked the Plan to pre-approve diagnostic facet joint injections. You say that this is necessary because you are in pain. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain when there is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity. 

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 diagnostic facet joint injections. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the documentation shows that you have radicular pain. Severe stenosis is present on the magnetic resonance imaging (MRI) provided. There are no signs of facet loading on exam. The requested facet injections are not medically necessary or reasonable 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint injections (64493, 64494, 64495).
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 transfer to an LTACH is medically necessary and appropriate. The Plan denied your request. The Plan says he criteria for admission to an LTACH are not met. The enrollee's status is stable and improving, and an LTACH would provide no therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level or until the clinical circumstances change such that an LTACH may be considered.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital.

The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 2D oral/facial photographic image provided on May 13, 2021.

You asked the Plan to pay for the 2D oral/facial photographic image. You say that your husband's x-ray was covered and yours was not. You say that this should be covered. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6242 x2) and three retainer crowns (D6750 x3).

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you do not have enough money to pay for these services. The Plan denied your request. The Plan says these services are not covered by your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two pontics (D6242 x2) and three retainer crowns (D6750 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy procedure
you had on May 6, 2021, at an outpatient hospital facility.

You asked the Plan to waive the copayment for the biopsy procedure. You say that this service should not be
considered a surgery but rather a diagnostic procedure. The Plan denied your request. The Plan says you were
charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for surgery and other services at an outpatient hospital facility.

You have been asked to pay a $225 copayment for the biopsy procedure. The biopsy procedure falls within the
"surgery and other services at an outpatient hospital facility benefit" category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the fine needle aspiration biopsy procedure you had on May 6, 2021, at an
outpatient hospital facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.

You asked the Plan to pre-approve 8 additional occupational therapy visits. You say that visits need to be added. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 8 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy and has been instructed in and is compliant in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.