Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

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 dental services 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 dental services. Our reviewer says that some of the dental services are medically necessary. The documentation shows tooth #20 has an existing crown with obviously defective margin on the mesial that is significant enough to warrant replacement. The reviewer found that the periodontal condition of tooth #20 is good, with minimal bone loss noted on radiograph. The reviewer found that the crown for tooth #20 is medically reasonable and necessary.

Therefore, we decided that the Plan has to pre-approve the crown for tooth # 20.

We also decided that the Plan does not have to pre-approve the crown for tooth # 19.
Our physician reviewer found the documentation shows tooth #19 has extensive caries that extends sub osseous and appeared to involve the furcation. The reviewer found that tooth # 19 is not reasonably restorable as the structural damage would not be amenable to any type of repair. The reviewer found that the crown for tooth # 19 is not medically reasonable and necessary.
Therefore, we decided that the Plan does not have to pre-approve the crown for tooth # 19.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV.
You asked the Plan to pre-approve the POV. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 POV have not been met. The documentation fails to indicate that you require a power scooter to complete mobility-related activities of daily living such as grooming, bathing, or eating within the home. Additionally, the power wheelchair is being requested for use outside of the home. Therefore, we decided that the Plan does not have to pre-approve the POV.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on November 6,2019 to the enrollee by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.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 referring provider 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. 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 forthe laboratory services provided on November 6, 2019 to the enrollee by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the records did not support the medical necessity for this service.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. It is not clear that the enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more appropriate. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120),
bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and
periodontal maintenance (D4910) provided on November 25, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you have been treated by this dentist for thirty
years and you want to continue seeing your dentist. The Plan denied your request. The Plan says the provider is
out-of-network.
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.
These services are not listed in your EOC; therefore, they are not covered your plan: intraoral - periapical first
radiographic image (D0220) and periodontal maintenance (D4910).
Furthermore, these services are not covered because you did not use an in-network provider: periodic oral
evaluation - established patient (D0120) and bitewings - four radiographic images (D0274). Your EOC clearly
states, EXCLUSIONS AND LIMITATIONS: Services performed by an out-of-network dentist if your plan
does not have out-of-network coverage. Therefore, we decided that the Plan does not have to pay for periodic
oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), intraoral -
periapical first radiographic image (D0220) and periodontal maintenance (D4910) provided on November 25,
2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (CPT 81401, 81219, 81402) for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this request is to rule out polycythemia vera.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the 2017 WHO Diagnostic Criteria for Polycythemia Vera and Essential Thrombocythemia as presented in the NCCN Guidelines Version 3.2019 Myeloproliferative Neoplasms. She does not have a subnormal EPO level, and there is no documentation of a bone marrow biopsy showing hypercellularity for age with trilineage growth. The enrollee would not have the required 3 major criteria. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (CPT 81401, 81219, 81402) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on September 12, 2019.
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 code 99214 is not payable under the OPPS fee schedule.
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every HCPCS code. We looked at the file and Medicare rules. The file shows that procedure code 99214 was billed under the OPPS fee schedule by the provider. This code has an OPPS status indicator of B and is not payable. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on September 12, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried Reacrit as required by step therapy rules.
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 Aranesp. Our reviewer says that the criteria for coverage of Aranesp have not been met. Our physician reviewer found the Plan requires a trial of Retacrit before they will approve the requested drug. The documentation does not support that the enrollee has tried Retacrit, or that this drug would likely be less effective, or have adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the presumptive drug testing. We decided that the Plan does not have to pay for the definitive drug testing.
You asked the Plan to pay for the presumptive drug testing. You say that this should be paid as it was ordered by the treating provider. The Plan says that the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
We decided that the Plan has to pay for the presumptive drug testing.
The Plan follows Medicare rules. Medicare rules say that laboratory testing may be covered when ordered by the treating provider. The documentation clearly shows that the treating provider, a network provider with the Plan, ordered a urine drug screening. This testing is not dependent on the number of analytes tested so it is not necessary for the provider to specifically document the drugs to be tested in a presumptive panel. Therefore, we decided that the Plan has to pay for the presumptive drug testing.
We also decided that the Plan does not have to pay for the definitive drug testing.
The Plan follows Medicare rules. Medicare rules say that laboratory testing may be covered when ordered by the treating provider.
While the documentation clearly indicates that the network provider intended to order definitive confirmation testing for this enrollee, the order is not sufficiently specific as to the number of drugs classes to analyze. Since we cannot confirm that the provider intended to order testing of 22 or more drug classes, the rules for payment of this code have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provent sleep apnea therapy.
You asked the Plan to pre-approve the therapy. 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. Medicare rules say that durable medical equipment is covered if it is designed to withstand repeated 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 the therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found although it appears to be modestly effective in the treatment of obstructive sleep apnea, this treatment does not meet the definition of durable medical equipment. It is not designed for repeated use, as it is disposable after a single night of use. It is therefore not coverable 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Provent sleep apnea therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on June 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forpodiatry services. You say that you would like this appeal reprocessed and approved for payment.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 withthe 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 has network providers available who can provide 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 forpodiatry services provided on June 13, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 11, 2019 to October 14, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that services were medically necessary.The Plan denied your request. The Plan says that coverage criteria were not met.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided October 11, 2019 to October 14, 2019.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 pulmonary diagnostic testing provided on September 4, 2019.
You asked the Plan to pay for the pulmonary diagnostic testing. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for pulmonary diagnostic testing provided on September 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin D assay (82306) provided on November 7, 2019.
You asked the Plan to pay for a vitamin D assay. You say that this was medically necessary. The Plan denied
your request. The Plan says this was a screening test.
The Plan must follow Medicare rules. Medicare rules say that a vitamin D assay is covered only for the
diagnoses listed above.
We looked at the file and Medicare rules. This procedure was not billed with a covered diagnosis. Based on this
information, we decided that Medicare rules for coverage of a vitamin D assay have not been met. Therefore,
we decided that the Plan does not have to pay for a vitamin D assay (82306) provided on November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient hospital care provided August 30, 2019 to September 1, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment as the inpatient hospital care provided wasmedically necessary.The Plandenied your request. The Plan says that prior approval was not obtained for the hospital admission.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IREinformation regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your requestas the medical records have not been providedin the case file for review.Therefore, we decided that the Plan has to pay forthe inpatient hospital care provided August 30, 2019 to September 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran MRI provided on October 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foran MRI. You say that you would like this claim reprocessed and approved for payment.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 has network providers available who can provide 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 foran MRI provided on October 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOcrevus (ocrelizumab) treatments.You asked the Planto pre-approvethe Ocrevus. You say that you feel that you should be allowed to transition to this drug.The Plandenied your request. The Plansaysthere is no clear reason that a change in therapy is required as the enrollee is maintained well on Betaseron.The Plan must follow Medicare rules. The rulessay 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 wascorrect in denying the request to pre-approve the Ocrevus. Our reviewer says that the requested use of Ocrevus is not shown to be medically reasonable and necessary for this enrollee. Our physician reviewer found at this time, it is not clear from the information provided for review why there is a need to change the patient's therapy for his multiple sclerosis. The records provided for review suggested that his MRIs had been stable. There was no evidence/indication of any relapses or significant disease progression which are the general indications for a transition of disease modifying therapy. There is nothing to suggest a clinical failure of Betaseron.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 Ocrevus have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOcrevus (ocrelizumab) treatments.