Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve laboratory services. You say that you do not want to go to the provider that is in-network. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 care that cannot be provided by network providers. 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 records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued SNF stay provided from January 21, 2021, to
January 23, 2021.
You asked the Plan to pay for the continued SNF stay. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
had no daily skilled need. The Plan also says that the enrollee was admitted to hospice on January 21, 2021.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the continued SNF stay provided from January 21, 2021, to
January 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the request is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Intracept procedure in the setting of low back pain have not been demonstrated in the peer-reviewed literature.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain that has failed conservative treatment at levels L3 through L5. A magnetic resonance imaging scan performed April 26, 2021, does not demonstrate Modic type changes. The report had a conclusory addendum made on May 12, 2021, that mild Modic I changes are present. These changes are not described in the body of the report. The medical records provided do not establish the medical reasonableness or necessity of the requested service, as defined by Medicare rules. The elements of the coverage rule are not satisfied.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) (CPT code 75574).
You asked the Plan to pre-approve the CTA. You say that you had a CT before that showed calcifications on your arteries, you underwent a sleep study that showed six (6) episodes of tachycardia while sleeping, you had a high pulse consistently for two (2) years and since then your shortness of breath has gotten worse. The Plan denied your request. The Plan says you had a normal resting electrocardiogram (EKG) on May 5, 2021, and there is no reason given why an EKG, or a stress echocardiogram could not be performed.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CTA. Our physician reviewer found there is no specific clinical rationale for the requested coronary CTA.
There is no contraindication to you undergoing a stress echocardiogram to assess for underlying coronary
artery disease. The review has determined that the requested CT scan is not medically reasonable or 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 the CTA have not been met. Therefore, we decided that the Plan does not have
to pre-approve CTA, heart, coronary arteries and bypass grafts (when present), with contrast material,
including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of
cardiac function, and evaluation of venous structures, if performed) (CPT code 75574).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from February 3, 2021, through February 24, 2021
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 psychotherapy services provided from February 3, 2021, through February 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatment (98940) provided on January 14, 2021, to February 18, 2021.
You asked the Plan to waive the copayment for chiropractic manipulative treatment. You say that you are being charged an incorrect copayment for your services. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $20 copayment for each Medicare covered visit for manual manipulation of the spine.
You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. The records show
you had three (3) visits for manual manipulation of the spine for a total cost share of $60 ($20 x 3 visits = $60).
The EOC confirms you are covered for eighteen (18) routine chiropractic services with a $10 copayment. The
services you received are not considered routine chiropractic care. You received manual manipulation of the
spine to correct subluxation; therefore, the EOC is clear that $20 is the required copayment for each visit.
Chiropractic manipulative treatment falls within the chiropractic services 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 chiropractic manipulative treatment (98940) provided on January 14,
2021, to February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) for tooth #7.
You asked the Plan to pre-approve a crown. You say that the tooth is deteriorating, and you are concerned about fracture. The Plan denied your request. The Plan says tooth #7 does not meet the criteria for a crown due to the clinically unacceptable root canal filling.
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 a 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 a crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the root canal is filled unacceptably, and the tooth cannot be further restored by any means without properly addressing the endodontic issue. The amount of missing structure (about 30%) would allow the tooth to be restored with a conventional composite and not require a crown restoration. 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 a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) for tooth #7.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for infusion therapy (96366) and a rituximab injection (J9312) provided on January 14, 2021.
You asked the Plan to waive the cost-share for infusion therapy and an injection. You say that you received a bill for services performed which was paid. You also say that you received another bill, eleven months later, for a significant increase of your cost share. The Plan denied your request. The Plan says the cost share you are being charged is correct.
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 20%
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must
pay a $50 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a 20% coinsurance for an injection. The allowed amount of the claim is $9,441.10,
resulting in a coinsurance obligation of $1,888.22. The EOC confirms that 20% is the required coinsurance for
Medicare Part B prescription drugs. You have also been asked to pay a $50 copayment for infusion therapy.
The EOC confirms that $50 is the required copayment for outpatient diagnostic tests and therapeutic services
including infusion therapy. Your total cost share is $1,938.22 ($1888.22 + $50 = $1,938.22).
The records show that the provider originally submitted a claim on February 12, 2020 for your injection;
however, the provider submitted a corrected claim on January 12, 2021, advising the correct units used for your
injection. By processing the corrected claim, the copayment remained the same for your infusion therapy and
the cost share for your injection processed with a 20% coinsurance amount of $1,888.22. The records also
show that you paid the provider $238.82; therefore, you will be responsible for $1,699.40 ($1,938.22 - $238.82
= $1,699.40).
Infusion therapy and an injection fall within the Medicare Part B prescription drugs and 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 cost-share
for infusion therapy (96366) and a rituximab injection (J9312) provided on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lipiflow thermal pulsation therapy.
You asked the Plan to pre-approve Lipiflow thermal pulsation therapy. You say that the requested service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of Lipiflow thermal pulsation therapy in the setting of Meibomian gland dysfunction has not been demonstrated in the peer-reviewed literature.
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 Lipiflow thermal pulsation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has dry eye syndrome from Meibomian gland dysfunction. The records indicate that other standard therapies are being attempted. Insufficient literature exists to support the requested treatment as standard of care. The provided medical records are insufficient to establish the medical necessity and reasonableness, as defined my Medicare rules, of the requested service. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lipiflow thermal pulsation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Lipiflow thermal pulsation therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erleada 60 mg tablet.
You asked the Plan to pre-approve Erleada. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Erleada 60 mg tablet.
Benefits for Erleada 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 pay for the prophylaxis (D1110), and the periodic oral evaluation - established patient (D0120) received January 13, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you have gone to this provider for 35 years and it is easy and convenient for you to get in and out of their office with a walker. The Plan denied your request. The Plan says you must receive your care from a provider who is eligible to provide services under Original Medicare.
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 when they are rendered by a provider who has opted out of Original
Medicare. The Plan has submitted evidence that this provider was opted out of Original Medicare on this date
of service. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), and the
periodic oral evaluation - established patient (D0120) received January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on June 23, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 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 pay for the urine PCR testing provided on June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of your health problem.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings (A6531).
You asked the Plan to pre-approve compression stockings. You say that you need these items. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings (A6531).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460), the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and the endodontic therapy, molar tooth (D3330) received March 19, 2021.
You asked the Plan to pay for the dental services. You say that the requested services were medically necessary. The Plan denied your request. The Plan says the requested services are 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 pay for the pulp
vitality tests (D0460), the consultation - diagnostic service provided by dentist or physician other than
requesting dentist or physician (D9310) and the endodontic therapy, molar tooth (D3330) received March 19,
2021.