Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins (D2950).
You asked the Plan to pre-approve the core buildup, including any pins. You say that this service should be covered. The Plan denied your request. The Plan says this service is not covered under your supplemental 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 pre-approve the core buildup, including any pins (D2950).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 3, 2020.
You asked the Plan to pay for home infusion therapy. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were billed with invalid codes.
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 CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery pack (E1399).
You asked the Plan to pre-approve a battery pack. You say that you need this to power your continuous positive airway pressure (CPAP) device when you have problems with electricity in your home. The Plan denied your request. The Plan says this is not a covered item.
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 battery pack (E1399).
Appeal type: Practitioner Services
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 bone marrow aspiration. You say that bone marrow aspiration is medically
necessary. The Plan denied your request. The Plan says this treatment is 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 bone marrow
aspiration. Our reviewer says that medical necessity has not been established. Our physician reviewer found
bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is needed to show
safety and efficacy of bone marrow aspirate. This service is not then covered by Medicare.
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 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 pre-approve a crown (D2750) for tooth #5.
You asked the Plan to pre-approve the crown. You say that a crown is necessary for tooth #5. The Plan denied your request. The Plan says the enrollee's tooth has an inadequate fill. The Plan also says that a cap cannot be approved for a tooth that has an inadequate fill from a root canal treatment.
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 when the services are medically necessary and reasonable. 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 crown. Our reviewer says that due to the poor prognosis of tooth #5 in its present state, evaluation and treatment of the inadequate root canal should be accomplished prior to placement of a new crown. Our physician reviewer found a review of the enrollee's dental record and radiographs indicates a defective crown in place and an inadequate root canal fill in tooth #5. Our physician reviewer also found that the inadequate root canal fill should be evaluated and treated prior to placement of a new crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF setting is the most appropriate for the
enrollee to reach desired outcomes. The Plan denied your request. The Plan says rules for pre-approval have
not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide and Formoterol Fumarate.
You asked the Plan to pre-approve Budesonide and Formoterol Fumarate (J3535). You say that you want the
enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under
the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide and Formoterol
Fumarate.
Benefits for Budesonide and Formoterol Fumarate (J3535) may be available under Medicare Part D. Contact
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (porcelain fused to noble metal) (D2752) to be inserted into an implanted tooth.
You asked the Plan to pre-approve the crown. You say that the crown will be inserted into an implanted tooth and is required to complete the dental work. You say that you are not able to chew well, and the denial of this service is affecting your health. The Plan denied your request. The Plan says implant-supported crowns are not covered by your supplemental dental benefit; the requested service is used for natural teeth only, not implants.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, a crown to be used with an implanted (non-natural) tooth is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (porcelain fused to noble metal) (D2752) to be inserted into an implanted tooth.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa, 20 mg/ml injections (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the injections are medically necessary. The Plan denied your request. The Plan says there is no documentation that shows the member is already using Euflexxa. The Plan also says that there is no evidence that the preferred drugs, Monovisc and Orthovisc, would be contraindicated.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found based on the provided documentation, the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc. The reviewer found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa, 20 mg/ml injections (J7323).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the patient does have an over 30 pack-year smoking history. The Plan denied your request. The Plan says the medical records do not show a tobacco smoking history of at least 30 pack-years
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria. We reviewed the file and the Medicare rules. We find that absence of signs/symptoms of lung cancer criteria and 30 pack-year smoking history criteria are not met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on February 25, 2021 with shortness of breath. The occupational therapy note on March 29, 2021 states that you need some assistance with grooming and dressing. The physical therapy note states you need minimal assistance with standing up and lying down. The records do not show that you require the intensity of services in an IRF. Specifically, you are not shown to be able to perform 15 hours per week of rehabilitative services and regular physician evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 11, 2020, through July 14, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you received a bill for the difference beyond your copayment. The Plan denied your request. The Plan says the copayment applied 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 $250 copayment per day, for days 1-7. A cost-sharing is charged for each inpatient stay. The copayment begins on the first day you are admitted and continues until the per-stay maximum out-of-pocket cost ($1,750) is paid. You have been asked to pay a $750 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay provided from July 11, 2020, through July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on November 3, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you saw the doctor for your shoulder and x-rays were taken. You say no surgical procedure was done and the $33.85 charge should be removed. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per day, per provider, for in-network Medicare-covered x-ray services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $35 copayment for the x-ray.
You have been asked to pay a $33.85 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you had an x-ray done on your left shoulder and clavicle during the visit. 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 x-ray provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (CT) (LDCT) for lung cancer screening.
You asked the Plan to pre-approve a LDCT for lung cancer screening. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that beneficiaries must meet all eligibility criteria for lung cancer screening with LDCT to be 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 LDCT for lung cancer screening. Our reviewer says that the services are not medically necessary. Our physician reviewer found at this time; a screening CT scan is not appropriate. A formal CT scan of the chest is appropriate, and it is indicated in the case file that the "office will ensure that it is ordered today."
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 LDCT for lung cancer screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (CT) (LDCT) for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on November 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99152 is not supported.
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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status, first 15 minutes. 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 pay for the moderate sedation services rendered on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve the temporary (interim) partial denture (D5820).
You asked the Plan to approve a temporary denture. You say that this is the only option available to fix your broken crown. The Plan denied your request. The Plan says that standard partial dentures can be covered by the Plan's dental benefit; however, all temporary items and services are excluded from coverage. Therefore, the temporary partial denture cannot be approved.
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, temporary items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to approve the temporary (interim) partial denture (D5820).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device.
You asked the Plan to pre-approve a CardioMems device. 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 CardioMems device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee 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 a CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an intravitreal injection provided on October 8, 2020.
You asked the Plan to waive the copayment for an intravitreal injection. You say that you disagree with the charges because you should only owe a $40 specialist copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received an intravitreal injection at an outpatient hospital facility on October 8, 2020. An intravitreal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for an intravitreal injection. An intravitreal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an intravitreal injection provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee would like to move forward with the radiofrequency ablation in order to decrease her level of pain and increase her activity level so she can maintain her quality of life. The Plan denied your request. The Plan says this service has not been proven as effective as standard treatment of SI joint pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).