Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve podiatry services. You say that you have had the most success with this
doctor. The Plan denied your request. The Plan says there are in-network providers available for these services.
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
podiatry 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 pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).
You asked the Plan to pre-approve the bone replacement graft and guided tissue regeneration. The Plan denied your request. The Plan says these services are not covered 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 pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten resin-based composites to be provided by an OON provider.
You asked the Plan to pre-approve the resin-based composites. You say that this enrollee was assigned to you by the health plan with Medicaid but not Medicare. The Plan denied your request. The Plan says you are not under contract with the enrollee's Plan. The Plan also says that in-network providers are available to the enrollee within the time and distance standard set forth by 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve ten resin-based composites to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics; foot inserts L3001, metatarsal bar L3410, and heel pads L3485. You say that you need the orthotics. The Plan denied your request. The Plan says requested documentation was not submitted from your physician supporting medical necessity.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records do not show that you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the inserts, metatarsal bar or heel pads.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The Plan contract includes a list of covered supplemental dental services. The contract specifically says that any procedure not listed is not covered. Core buildup, including any pins when required (D2950) is not included on this list and is not a covered supplemental benefit. You can find this information on pages 21 to 29 of the Plan's 2020 Preventive & Comprehensive Dental Coverage Customer Handbook.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that your lumbar stenosis is so severe, that you are
unable to walk at times. The Plan denied your request. The Plan says currently, your treatment plan can be
transitioned to an appropriately qualified in-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. 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 referral to an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit and a laryngoscopy
provided on October 23, 2019.
You asked the Plan to waive the deductible for the specialist office visit and the laryngoscopy. You say that
you would like to continue your provided for your follow-up care. You say you would like the claim
reprocessed. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1,000 deductible that applies towards out-of-network specialist
office visits and out-of-network laryngoscopies.
The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The laryngoscopy you asked the Plan to
waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that
applies towards out-of-network specialist office visits and out-of-network laryngoscopies. This cost sharing is a
contractual obligation that had not been met at the time the office visit and the laryngoscopy were received on
October 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the specialist
office visit and the laryngoscopy provided on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Lumbar Vertiflex Interspinous Spacer
(22869).
You asked the Plan to pre-approve the insertion of a Lumbar Vertiflex Interspinous Spacer. You say that this is
medically necessary. 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 Lumbar Vertiflex
Interspinous Spacer. Our reviewer says that the requested service are is considered medically reasonable and
necessary in this case. Our physician reviewer found the spacer remains experimental in spine surgery. More
research is needed to show safety and efficacy. Also, there is no documented spinal instability. The device is
not needed at this time.
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 Lumbar Vertiflex Interspinous Spacer have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Lumbar Vertiflex
Interspinous Spacer (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 the enrollee is currently undergoing treatment at an acute care hospital (ACH)following a cardiac arrest. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is noted to be unresponsive. It is unclear that ventilator weaning or decannulation are achievable. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection without imaging guidance.
You asked the Plan to pre-approve the injection. You say that you are in excruciating pain, and you need this
procedure done as soon as possible. The Plan denied your request. The Plan says the clinical information
provided does not describe a plan to use fluoroscopy or CT guidance and, therefore, the requested procedure is
not indicated at this time.
The Plan must follow Medicare rules. The rules say that epidural injections must be done with fluoroscopy or
CT guidance.
The requested injection is intended to be done without imaging guidance. The definition of the requested code -
CPT 62322 - is "Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid,
steroid, other solution), not including neurolytic substances, including needle or catheter placement,
interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance." Based on this
information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we
decided that the Plan does not have to pre-approve an epidural injection without imaging guidance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on September 18, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records from the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.
We find that the billed codes are not supported in the medical record. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your therapy does not require close physiatrist supervision, or a multidisciplinary team approach.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our physician reviewer found that you presented to the acute hospital with a fall resulting in a right knee periprosthetic fracture. You were treated in the hospital with orthopedic consultation and a surgical repair of the fracture was performed. You are unsteady on your feet. You are toe-touch weight bearing with the right lower extremity with a knee brace, and are walking 35 feet using a rolling walker with minimum assistance. You are at minimum to moderate assist for transfers, and require maximum assist for lower body activities of daily living and toileting. You are medically stable, and your pain is controlled with oral medication. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy services, but you do not require an intensive inpatient rehabilitation therapy program. There is not documentation that the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility is 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for conscious sedation (D9248) provided December 9, 2019.
You asked the Plan to pay for the sedation. You say that the sedation was medically necessary. The Plan denied your request. The Plan says this service was not a covered 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 conscious sedation (D9248) provided December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBRCA 1&2, PALB2, ATM, Myrisk Hereditary Cancer Update Panel.You asked the Plan to pre-approveBRCA 1&2, PALB2, ATM, Myrisk Hereditary Cancer Update Panel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered only when an individual with a breast cancer was diagnosedon or before 45 years old.We looked at the file and Medicare rules. Review of the file shows that the enrollee was diagnosed with breast cancer at age 68. Based on this information, we decided that Medicare rules for coverage of BRCA 1&2, PALB2, ATM, Myrisk Hereditary Cancer Update Panel have not been met.Therefore, we decided that the Plan does not have to pre-approveBRCA 1&2, PALB2, ATM, Myrisk Hereditary Cancer Update Panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant supported crown (D6059).
You asked the Plan to pay for the crown. You say that the crown is medically necessary. The Plan denied your request. The Plan says the tooth was extracted prior to enrollment in the plan, therefore the requested crown is not a covered 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 an implant supported crown (D6059).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right facet joints
at L1-L3.
You asked the Plan to pre-approve the RFA procedure. You say that this treatment should be allowed in order
to assist in pain relief. The Plan denied your request. The Plan says the enrollee has received the maximum
number of facet joint injections in the current rolling 12 month period.
The Plan must follow Medicare rules. Medicare rules say that coverage for facet joint interventions is limited to
five total within a rolling 12 month year.
In this case, the enrollee has already received five lumbar facet joint injection procedures since August 12,
2019. As such, further sessions are not covered until August 2020. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) of the right facet joints at L1-L3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia syringe.You asked the Plan to pre-approveProlia syringe. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug will bedispensed in a pharmacy so it is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought tothe office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveProlia syringe.Benefits for Prolia syringemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for the Tempus gene panel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered 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 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 Tempus gene panel provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the records provided show that the enrollee has not completed the full course of care in the current acute care hospital setting. The Plan says that the guidelines for coverage of LTACH care have not been met.
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 ongoing care needs include oxygen supplementation, intravenous antibiotics, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 long term acute care hospital (LTACH) services.