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

We decided that the Plan has to pre-approve complete maxillary denture, extractions of teeth 28 and 29, and removal of roots for tooth 2.

You asked the Plan to pre-approve dental services. You say that you are appealing. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because there are no clinical records provided which include a full set of X-Rays.

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 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 dental services. Our reviewer says that you meet the criteria for the requested dental services. Our physician reviewer found the documentation provided indicated an edentulous maxillary arch with the exception of the residual roots of tooth number 2. Teeth numbers 28 and 29 showed breakdown requiring extractions.

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 dental services have been met. Therefore, we decided that the Plan has to pre-approve complete maxillary denture, extractions of teeth 28 and 29, and removal of roots for tooth 2.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve definitive drug testing of 22 or more drug classes for the
enrollee.
You asked the Plan to pre-approve the definitive drug testing. You say that the test was ordered to identify
specific drug use for ongoing safe prescribing of controlled substances. The Plan denied your request. The Plan
says the test to see how much exactly of each drug in the enrollee's system is not needed to help guide care.
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is only covered under certain
medical indications.
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 definitive drug testing. Our
physician reviewer found that the enrollee has a history of chronic pain. There is no mention of concerning
symptoms or misuse. The presumptive testing is consistent with prescribed medical therapy. There is no
unexpected screening test for drugs of abuse in the medical record to justify a quantitative drug test. Therefore,
the requested drug testing is not medically reasonable and necessary to treat the enrollee's 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 definitive drug testing have not been met. Therefore, we decided that the
Plan does not have to pre-approve definitive drug testing of 22 or more drug classes for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram provided on October 16, 2019.You asked the Plan to waive the copayment foran electrocardiogram. You say that you disagree with the charges.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 $10 copayment per day for outpatient diagnostic tests. You have been asked to pay a $10 copayment for an electrocardiogram. An electrocardiogram falls within the outpatient diagnostic tests and therapeutic services and supplies 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 foran electrocardiogram provided on October 16, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve phototherapeutic keratectomy (PTK).
You asked the Plan to pre-approve phototherapeutic keratectomy. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not
medically necessary.
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 phototherapeutic keratectomy. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has a history of granular dystrophy. The enrollee was complaining
of blurry vision in the left eye without pain. The enrollee was using Refresh drops twice a day and Celluvisc
every evening. The slit lamp exam was remarkable for bilateral central anterior stromal bread crumb like
opacities with clear intervening spaces without epithelial defect. Granular dystrophy is a corneal stromal
dystrophy that clinically presents as granular lesions in the anterior stroma. Early in the disease process, no
treatment is needed. When recurrent erosions occur, these may be treated with therapeutic contact lenses,
superficial keratectomy or PTK (phototherapeutic keratectomy). When visual acuity is affected, PTK or
penetrating keratoplasty can be performed, however, the granular deposits will often return. The enrollee has
granular dystrophy with symptoms of worsening vision in the left eye which can be treated by PTK. PTK is
used in the treatment of granular dystrophy to improve visual acuity and to treat recurrent corneal erosions.
Based on the enrollee's history and current exam, it is medically necessary and reasonable to have PTK on the
left eye. The enrollee has noticed a decrease in vision the left eye as compared to the right eye which is
reflected in the best corrected VA. PTK would be a reasonable choice in improving this enrollee's visual acuity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of phototherapeutic keratectomy have been met. Therefore, we decided that the
Plan has to pre-approve phototherapeutic keratectomy (PTK).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on December 3, 2018.
You asked the Plan to waive the copayment for the EKG. You say that you say the EKG is a routine procedure and should not be billed extra. The Plan denied your request. The Plan says you have been charged 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 $10 copayment per day for Medicare-covered tests. You have been asked to pay a $10 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the EKG was an additional service.
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 EKG provided on December 3, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by a non-contracted provider.
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 the services were rendered by a non-contracted 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 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 for the medical services provided on December 30, 2019 by a non-contracted provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the computerized dynamic posturography sensory organization test provided on January 17, 2020. You asked the Plan to pay for the computerized dynamic posturography. You say that this test was medically necessary. The Plan denied your request. The Plan says that this test was not authorized or medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the computerized dynamic posturography by a contract provider. The file does not show that the plan provided notice to you that the computerized dynamic posturography would not be covered. Under Medicare rules, this means the computerized dynamic posturography is considered approved by the plan. Therefore, we decided that the Plan has to pay for the computerized dynamic posturography sensory organization test provided on January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on December 28, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges.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 $60 copayment for CT scans. You have been asked to pay a $60 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 fora CT scan provided on December 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Denosumab (Prolia).You asked the Plan to pre-approve the Denosumab (Prolia). You say that the enrollee has severe osteoporosis without current pathological fracture. You also say that the enrollee is not a candidate for forteo.The Plan denied your request. The Plan says they did not receive information addressing that the enrollee has either a history of osteoporosis-related fracture or has failed or has a contraindication to Zoledronic Acid.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 the Denosumab (Prolia). Our reviewer says that the criteria coverage has not been met. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer found that the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer also found that the enrollee does not have a history of osteoporotic fracture or had previous treatment, contraindication, or intolerance to Zoledronic Acid. 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 Denosumab (Prolia) have not been met.Therefore, we decided that the Plan does not have to pre-approve the Denosumab (Prolia).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for a urinary tract infection and left elbow abrasion. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve facet injections. You say that the evaluation indicates thoracic and lumbar facet pain. The Plan denied your request. The Plan says that the enrollee has not undergone dual medial branch blocks to establish facet joints as the origin of pain.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain medical indications. The file shows that facet injections were requested for T9-10, T10-11, T11-12, L3-4, L4-5, and L5-S1 (CPT Codes 64490-64495). 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 facet injections. Our physician reviewer found that the enrollee has chronic lower thoracic and low back pain without radiation. She has pain referable to thoracic and lumbar facet joints on physical examination. She has had physical therapy, acupuncture, massage, Ice/heat, TENS and chiropractic therapy. The request is for facet joint blocks. The Plan states these are therapeutic as opposed to diagnostic. However, this is not stated in the progress notes. The enrollee has probable facet joint disease. Therefore, the requested procedures are 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 facet injections have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tekturna. You asked the Plan to pre-approve Tekturna. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Tekturna.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 90882) provided to the enrollee on August 29, 2019, and August 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The requested services were not provided for the diagnosis or treatment of an illness or injury. This means that the services in question were not considered medically necessary. Additionally, CPT code 90882 is assigned a status indicator of "N" under the physician fee schedule, which means this service is not covered by Medicare. 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 pay for the services (CPT 90882) provided to the enrollee on August 29, 2019, and August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brilinta.You asked the Plan to pre-approve Brilinta. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered 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 Brilinta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve22 additional physical therapy (PT) visits.You asked the Plan to pre-approve the additional PT visits. You say that the enrollee's limited range of motion does not allow him to participate in an effective home exercise program.The Plan denied your request. The Plan says the enrollee was approved for two more visits in order to allow for training in a home exercise program.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 the additional PT 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 the patient has had extensive prior therapy visits and the documentation does not reveal evidence of skilled needs beyond what was approved by the health plan. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide ongoing treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been instructed in a treatment plan and the health plan had allowed for additional sessions to complete education on a home program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora lipid panel provided by a participating provider on December 16, 2019.You asked the Plan to waive the copayment for lab work. You say that this was part of your annual wellness exam. You say that you shouldn't have a copayment for this. The Plan deniedyour request. The Plan says services were provided that went beyond an annual wellness exam; therefore, the correct copayment has been applied.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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. Lab work falls within theoutpatient diagnostic tests/laboratory tests 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 a lipid panel provided by participating provider on December 16, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).