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

We decided that the Plan does not have to pre-approve bridge for teeth #23, 24, 25, 26 (D6240) and bridge for teeth #22 and #27 (D6750).
You asked the Plan to pre-approve the dental services. You say that you are recommending a 8 unit bridge. A lower partial is not an option since the enrollee has a severe gagging reflection. The Plan denied your request. The Plan says this service is not covered under the benefit package.
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 health plan contract says that any service not listed under the Description of Benefits is not covered. 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 bridge for teeth #23, 24, 25, 26 (D6240) and bridge for teeth #22 and #27 (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.
You asked the Plan to pre-approve the mandibular partial denture. You say that you believe the enrollee's
circumstances for the replacement period may be an exception. You also say that the enrollee was the victim of
a domestic assault in which her partial was thrown away. The Plan denied your request. The Plan says this
service exceeds the maximum count allowed per period.
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, partial dentures are limited to one
procedure every five years. The record shows that you received a partial denture on April 10, 2018 and your
partial denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a
mandibular partial denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Toric intraocular lens.You asked the Plan to pre-approveToric intraocular lens. You say that you need this lens to correct for optimal vision, and without this lens you will still need eyeglasses.The Plan denied your request. The Plan says the denial of authorization for this lens is correct, because the Plan only covers a standard intraocular lens so you would pay the difference in cost between this specialty intraocular lens and a standard intraocular lens.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers standard intraocular lenses, and members need to pay the difference for other non-covered specialty intraocular lenses.We looked at the file and the Plan's rules. The plan only covers a standard intraocular lens, so you would need to pay the difference in cost for the requested Toric intraocular lens. Based on this information, we decided that the Plan's rules for coverage of Toric intraocular lens have not been met.Therefore, we decided that the Plan does not have to pre-approvea Toric intraocular lens.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled nursing facility services (SNF).
You asked the Plan to pre-approve the SNF services. You say that the enrollee still cannot walk without assistance and the wife is unable to care for him on her own at home. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled nursing facility services (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on June 8, 2019.
You asked the Plan to pay for the services provided. You say that you work hard to provide a fast and efficient
diagnostic service. The Plan denied your request. The Plan says the diagnosis billed does not meet coverage
criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing
why the lab services provided were medically necessary.
We looked at the file and Medicare rules. In this case, there were insufficient records provided to show the
results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy
for disease or illness present in the enrollee at the time of service. 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 to the enrollee on June 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (G0500) provided on July 31, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 G0500 is moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate). We find that CPT code G0500 is not supported in the medical record. Specifically, the record does not indicate that an independent trained observer was present. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (G0500) provided on July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99291 provided on April 10, 2019.
You asked the Plan to pay for CPT code 99291. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, procedure code 99291 is a time based code. In order to bill CPT 99291, the documentation must note the first 30-74 minutes that was spent providing services to the enrollee. The progress note for April 10, 2019 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of CPT 99291. Based on this information, we decided that Medicare rules for coverage of CPT code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99291 provided on April 10, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1 GM capsules.
You asked the Plan to pre-approve Vascepa capsules. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Vascepa capsules are 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 Vascepa 1 GM capsules.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve porcelain or ceramic retainer crowns (code D6740) for tooth #'s 2 and 4 and a porcelain or ceramic pontic (code D6245).
You asked the Plan to pre-approve the retainer crowns and pontic. You say that due to the enrollee's recurrent caries underneath tooth #2, bridges are recommended. You also say that there is too much of a gap underneath the pontic - porcelain crown and gum, and the current porcelain crown has chipped off as well. The Plan denied your request. The Plan says that the x-rays do not show any recurrent caries for medical necessity.
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 retainer crowns and pontic 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 retainer crowns and pontic. Our reviewer says that the enrollee needs these services. Our physician reviewer found the documentation indicating that the present fixed bridge replacing tooth #3 is defective due to recurrent caries and fracture. Our reviewer also found that the services meet the criteria for coverage for a new bridge. 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 retainer crowns and pontic have been met. Therefore, we decided that the Plan has to pre-approve porcelain or ceramic retainer crowns (code D6740) for tooth #'s 2 and 4 and a porcelain or ceramic pontic (code D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 11, 2019 by an out of
network provider.
You asked the Plan to pay for wound care. You say that the enrollee is responding to the treatment in a great
manner. You say that additional treatments is only for the well-being of the patient. The Plan denied your
request. The Plan says there are in-network providers available for the services that were provided.
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 June 11, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine
for the enrollee.
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have elevated
cortisol levels and an elevated testosterone level. There is no objective evidence or laboratory evidence of
thyroid issues. While screening of the neck/thyroid for a sub-clinical mass/lesion may be reasonable, this could
be conducted via ultrasound rather than CT. The documentation does not support that the requested CT scan is
currently medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the cervical spine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferumoxytol injection provided on June 5, 2019.
You asked the Plan to waive the coinsurance for the ferumoxytol injection. You say that the hospital is in-network. You say that you previously had the same tests at the hospital and paid nothing. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $98.84, which is 20% of the allowed amount for the ferumoxytol injection. The allowed amount is $494.19 (20% x $494.19 = $98.84). The ferumoxytol injection falls within the "Medicare Part B Prescription Drugs" 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 coinsurance for the ferumoxytol injection provided on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the colon cancer screening to be provided by the out of network provider.
You asked the Plan to pre-approve the physician service. You say that this doctor is willing to provide you with a diagnostic virtual colonoscopy. You also say that you were unable to find an in network provider who would perform a virtual colonoscopy. The Plan denied your request. The Plan says the requested service can be provided in network. The Plan also says this service may be covered under the Easy Travel - Traveler Benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the colon cancer screening to be provided by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve the consultation. 
You say that you would like to continue the course of treatment. The Plan denied your request. The Plan says you can be safely evaluated by an in-network allergist who can provide the appropriate evaluation and care that your condition requires.
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 pre-approve 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes E0667-NU-LT and E0667-NU-RT provided on June 28, 2019.
You asked the Plan to pay for CPT codes E0667-NU-LT and E0667-NU-RT. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for CPT codes E0667-NU-LT and E0667-NU-RT provided on June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient care for (27280) open SI joint fusion for the enrollee.
You asked the Plan to pre-approve 27280 for open SI joint fusion. We note the plan approved codes 22852, 22612, 22633, 22848, 22853, 22842 and (1) day Inpatient hospital stay. You say that this surgery is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established for SI joint fusion.
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 27280 for open SI joint fusion. Our physician reviewer found this enrollee presents with complaints of low back pain with intermittent lower extremity numbness, tingling and burning. He is status post L4-S1 fusion with reported radiographic evidence of screw fracture without instability. There is reported solid fusion at the L5/S1 level. Significant functional limitations are noted in activities of daily living. Lumbar spine revision surgery has been approved to include L4/5 fusion exploration, hardware removal, fusion from L4-S2. The request for CPT code 27280 for open SI joint fusion has been denied. Current evidence based medical guidelines and literature criteria have not been met to support SI joint fusion. There is no documentation of any SI joint complaints or diagnosis. There is no clear evidence of a condition for which SI joint fusion is supported by current medical evidence. There is no clinical evidence of at least 3 positive SI joint provocative tests, or imaging evidence of SI joint spondyloarthropathy. There is no documentation that this enrollee has failed at least 6 months of non-surgical treatment directed to the SI joints or had a positive SI joint diagnostic block. Therefore, the requested SI joint fusion would not be considered the standard of care or reasonable and medically necessary for treatment of the enrollee's low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 27280 for open SI joint fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient care for (27280) open SI joint fusion for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain or ceramic crowns (code D2740) on tooth #'s 3 and 4.
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the services are not medically necessary.
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 crowns 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 crowns. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided x-rays show an existing two surface restoration on tooth #4 with both cusps intact. Our reviewer found that tooth #3 is difficult to see on the provided x-ray, however it does not appear that any cusps are involved despite some existing restoration. Our physician reviewer found that there does not appear to be extensive damage to either tooth and, given the provided x-rays, it appears both teeth may be restored conventionally without full coverage crowns. Our reviewer also found that the requested treatment is not considered medically necessary. 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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic crowns (code D2740) on tooth #'s 3 and 4.