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

We decided that the Plan does not have to pre-approve quantitative computed tomographic (CT) coronary calcium scoring.
You asked the Plan to pre-approve the quantitative CT coronary calcium scoring procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is a screening test and is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Screening tests for asymptomatic patients are not considered reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the quantitative CT coronary calcium scoring procedure. Our reviewer says that while this imaging may be appropriate, it is not considered medically reasonable and necessary based on Medicare guidelines as it is considered a screening test. Our physician reviewer found the use of CT coronary calcium scoring is routine in the assessment of atherosclerotic heart disease in order to stratify risk for future coronary events in patients shown to have persistently elevated total cholesterol and especially LDL levels as does this patient. Current clinical practice standards would support the requested test as indicated and medically necessary. However, the NCD guidelines do not allow for screening tests such as CT coronary scoring in asymptomatic patients.
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 quantitative CT coronary calcium scoring procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve quantitative computed tomographic (CT) coronary calcium scoring.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on November 2, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify the enrollee's benefits.

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 first intraoral periapical x-ray provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown lengthening procedures (D4249) provided on December 14, 2020 by an out-of-network provider.
You asked the Plan to pay for the crown lengthening procedures. You say that you thought these services would be covered and the Plan would pay half the cost. The Plan denied your request. The Plan says out-of-network dental care is not covered.
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 provided outside the Plan's dental network. Therefore, we decided that the Plan does not have to pay for the crown lengthening procedures (D4249) provided on December 14, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening provided on September 10, 2020.
You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicaredenies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients withsuspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the cardiovascular disease screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. To report cardiovascular screening services, specific CPT codes must be billed. Additionally, the documentation submitted does not include clinical information to determine why this testing was ordered. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease screening provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and resin-based composites provided on October 5, 2020, and November 30, 2020.

You asked the Plan to pay for the core buildup and resin-based composites. You say that you feel like you were misinformed because you were told that you could go to any dentist. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 20, 2015, to December 20, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.

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 covered when they are received by a Medicare opt out provider. The record shows that you made no contacts to the Health Plan in regard to your cost share or with provider questions prior to receiving the above referenced services. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required and resin-based composites provided on October 5, 2020, and November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of April 20, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are still in the hospital. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric level of care is correct, as you no longer meet criteria for this level of care, and you can receive care in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that you do not meet the Medicare criteria for continued inpatient psychiatric level of care. Our physician reviewer found it was not expected that you would improve in a reasonable period of time beyond April 20, 2021 as you did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. It does not appear that active treatment was taking place beyond April 20, 2021, or that the services are reasonably expected to improve your condition or for the purposes of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (97110) provided on September 13, 2019.
You asked the Plan to pay for the non-covered chiropractic services (97110). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services with code 97110 are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue, with code 97110 is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (97110) provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 8, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. 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 physician's services provided on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral Prednisone.

You asked the Plan to pre-approve oral Prednisone. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this medication is not covered under Medicare Part B.

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 oral Prednisone.

Benefits for oral Prednisone 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 problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, periodic oral exam, bitewing x-rays, prophylaxis, topical application of fluoride varnish, and oral hygiene instructions provided on August 19, 2019, and August 26, 2019 by an OON provider.

You asked the Plan to pay for the dental services. You say that you were not aware that this provider is OON. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services from non-contracted providers are excluded from coverage.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, periodic oral exam, bitewing x-rays, prophylaxis, topical application of fluoride varnish, and oral hygiene instructions provided on August 19, 2019, and August 26, 2019 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional trips.

You asked the Plan to pre-approve 60 additional trips. You say that you would like reconsideration because you require additional trips to attend dialysis treatments.The Plan denied your request. The Plan says this service is not covered as you have exhausted your 2021 benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve 60 additional trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that inpatient level of care is appropriate.The Plan denied your request. The Plan says that the records received do not show the enrollee has health problem that will require the enrollee to stay in the hospital after this procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. There is no clinical rationale for the requested inpatient admission. The enrollee by history has two types of seizures. The procedure can be obtained at an observation level of care. The record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care would span two midnights.Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve the physical therapy services. You say that you would like reconsideration
because you need physical therapy and the requested provider is 5 minutes from your facility. The Plan denied
your request. The Plan says there are no extenuating circumstances related to geographic access, compelling
continuity of care making it medically necessary that future care come only from this provider, or unique
medically-recognized qualifications of the requested out-of-network provider to justify prior authorization of
out-of-network benefits.

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. 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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1110, D1206, D2335, D2391) received from an out-of-network (OON) provider.

You asked the Plan to pay for the dental services. You say that this provider participates in the Plan's network.The Plan denied your request. The Plan says items and services received from an out-of-network provider are not covered.

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 Plan does not cover items and services received out-of-network. The Plan has confirmed that the provider in this case was not in-network on the date(s)of service.Therefore, we decided that the Plan does not have to pay for the dental services (D1110, D1206, D2335, D2391) received from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 27, 2020.

You asked the Plan to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. You say that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was medically necessary. The Plan denied your request. The Plan says the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was 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 Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. Our reviewer says that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary. Our physician reviewer found the therapy provided to the member on the date(s) of service under review involved Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical for the member's low back pain. The treatment provided has not been well validated for use in any well-designed clinical studies. The requested therapy is not currently recognized by any professional organization/society as being a safe and effective manner of addressing low back pain (or other etiologies of neuropathic pain).

Given the need for well-designed prospective studies to be performed involving this technology, this service cannot be said to reflect the generally accepted standards of practice and/or care. Rather, the services furnished would more adequately be described as being investigational in nature. For these reasons, these services would not have met/satisfied the Medicare definition of medical necessity.

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 Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular surgery office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are no extenuating circumstances related to geographic access, compelling continuity of care making it medically necessary that future care come only from this provider, or unique medically recognized qualifications of the requested out of network provider to justify prior authorization of out of network benefits.

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. 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 a vascular surgery office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

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 the enrollee is medically stable without any skilled nursing needs and no need for skilled physical therapy services.

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 the enrollee's 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 for the enrollee.