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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of an upper extremity.
You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the documentation does not include results of an X-Ray or that the enrollee had a recent 6-week trial of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found a plain X-Ray is a reasonable and necessary requirement prior to MRI testing. Therefore, at this point the requested MRI is not 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of an upper extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral exam and the crown.
You asked the Plan to pay an additional amount for the exam and crown. You say that you think the plan should pay more for the services. The Plan denied your request. The Plan says you are responsible for the difference between what the out-of-network provider charges and the maximum allowable charge plus the standard cost share for the item or service provided, therefore the correct cost share applied.
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 reimbursement is in excess of this benefit. The provider in this case is out-of-network. The Plan contract states that you may be billed more by an out-of-network provider if the charge is greater than the Maximum Allowable Charge (MAC). The provider charged $53 for the oral exam. The Plan's Maximum Allowable Charge for the oral exam was $19, therefore you are responsible for the difference between what the provider charged and the allowable amount ($53 - $19 = $34). The provider charged $1,150 for the crown. The Plan's Maximum Allowable Charge for the crown was $520. The crown requires a 50% coinsurance from an out-of-network provider. Therefore, your cost share for the crown is the 50% coinsurance plus the difference between what the provider charged and the Plan's Maximum Allowable Charge ($260 + $630 = $890). Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral exam and the crown.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs 6 weeks of intravenous antibiotic therapy. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.
You asked the Plan to pre-approve a panniculectomy. You say that the requested panniculectomy is medically necessary. The Plan denied your request. The Plan says the requested panniculectomy 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 pre-approve a panniculectomy. Our reviewer says that the requested panniculectomy is not medically necessary. Our physician reviewer found in this case, the elements of the local coverage determination are not satisfied because the document provided does not indicate that the enrollee has impaired walking ability, chronic pain or ulceration from the intertrigo, or that the intertrigo has not been responsive to standard treatment for a period of more than three months. The requested service cannot be recommended based upon the documentation provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom ankle splints.
You asked the Plan to pre-approve the requested items. You say that you need the splints for daily foot drop control. The Plan denied your request. The Plan says the documentation does not show the splints are needed for stabilization.
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses are 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 requested items. Our physician reviewer found that you have a past medical history of bilateral foot drop. Replacement right and left custom ankle splints have been requested because your prior splints no longer fitting due to excessive weight loss. There is no documentation from the prescribing provider which clearly states you have the potential to benefit functionally. There is not complete documentation that the requested splints 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 the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve custom ankle splints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH admission. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. No clinical documentation was provided to confirm that the enrollee meets coverage criteria. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 30, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration because train of four testing is necessary for determining diagnostic neural integrity from each surgical innervated structure. The Plan denied your request. The Plan says the documentation submitted does not support the units billed.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Specifically, train of four monitoring is considered integral to the primary procedure and not separately reimbursable. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan with quantitative calcium scoring (75571).
You asked the Plan to pre-approve a CT scan with quantitative calcium scoring. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary. We looked at the file and Medicare rules. The requested service is not covered. Based on this information, we decided that Medicare rules for coverage of a CT scan with quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan with quantitative calcium scoring (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on October 12, 2020.
You asked the Plan to waive the copayment for an ECG. 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 $45 copayment for diagnostic procedures and tests provided in a specialist's office You have been asked to pay the allowed amount of $17.48, which is less than the $45 copayment for an ECG. An ECG 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 for an ECG provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that in your medical judgment this enrollee will particularly benefit from the less invasive approach offered by this device as compared to a more invasive laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of your health problems.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 7, 2020.
You asked the Plan to pay for the occlusal guard. You say that you were under the impression that this was covered. You say that this was covered when you received another one two years prior, and when you got the guard your dental provider told you the Plan would pay for it. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit. The Plan has indicated that they have opened a separate review to address your grievance.
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 occlusal guard (D9944) provided on July 7, 2020.
Your complaint about possible misinformation about covered services from a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 retainer crowns (D6750) and a pontic (D6240).
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not
listed as a covered service either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 2
retainer crowns (D6750) and a pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a gingivectomy or gingivoplasty (D4212), the unspecified restorative service (D2999), and an occlusal adjustment (D9951).
You asked the Plan to pre-approve the dental services. You say that you have a cavity under your crown. You say that if it goes untreated, it will cause infections. You also say that if this is left untreated, this could cause complications that could heighten your risk for Covid-19. The Plan denied your request. The Plan says the requested services are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a gingivectomy or gingivoplasty (D4212), the unspecified restorative service (D2999), and an occlusal adjustment (D9951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application (D1206), the surgical extraction
(D7210), the local application of antimicrobial agent (D4381 x 2), the scaling and root planing for 4 or more
teeth per quadrant (D4341 x 2), the scaling and root planing for 1 to 3 teeth per quadrant (D4342), and the local
anesthesia (D9215) provided on October 20, 2020.
You asked the Plan to pay for the fluoride application, surgical extraction, and the local application of
antimicrobial agent. You say that the services were necessary. You say that you went to another dentist who
advised that you needed the procedure done. You say that that dentist did not accept your insurance and you
could not afford the services. The Plan denied your request. The Plan says the application of fluoride is not
listed as a covered service. The Plan says that extraction is not listed as a covered service. The Plan also says
local application of antimicrobial agent is not listed as a covered service either.
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
fluoride application (D1206), the surgical extraction (D7210), the local application of antimicrobial agent
(D4381 x 2), the scaling and root planing for 4 or more teeth per quadrant (D4341 x 2), the scaling and root
planing for 1 to 3 teeth per quadrant (D4342), and the local anesthesia (D9215) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for vision specialist services provided on September 23, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $50 copayment for vision services. 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 $50 copayment charged for vision specialist services provided on September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
You asked the Plan to pre-approve Restasis. The Plan denied your request. The Plan says this is not covered under enrollee's Part B plan.
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 Restasis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is necessary because the enrollee has had symptoms for 14 years. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show that it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).