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

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 31, retainer crowns (D6740) for teeth # 18 and 20, and the pontic (D6245) for tooth # 19.

You asked the Plan to pre-approve the dental services. You say that you are only missing 1 tooth. You also say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the crown for tooth # 31 and the bridge are not medically necessary. Our physician reviewer found the provided documentation indicates that the crown appears adequate and there was no narrative in the documentation indicating the reason for the replacement. The reviewer found that the provided documentation does not indicate why a removable appliance would be contraindicated. Therefore, the reviewer found that the requested crown and bridge are not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 31, retainer crowns (D6740) for teeth # 18 and 20, and the pontic (D6245) for tooth # 19.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic (CPT code 81479) provided to the enrollee on January 19, 2021.

You asked the Plan to pay for the laboratory testing. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not covered based on Medicare rules.

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 laboratory testing. Our physician reviewer found the records indicate that the enrollee has a diagnosis of major depression. The records submitted do not provide documentation from the clinician that addresses the coverage criteria. The order of medical necessity documentation submitted is internally inconsistent and not credible. The coverage criteria 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 the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic (CPT code 81479) provided to the enrollee on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010) for tooth #19.

You asked the Plan to pre-approve the endosteal implant. You say that you need the implant for eating and chewing. The Plan denied your request. The Plan says that your dentist has asked to replace more than one tooth in this part of your mouth with an implant.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the endosteal implant when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the endosteal implant. Our reviewer says that the documentation provided meets the criteria for coverage for a dental implant (D6010) to replace missing tooth #19. Our physician reviewer found according to the rules of coverage only one implant is allowed in an area to replace a missing tooth. Our reviewer also found that the documentation provided does not indicate any other implants in the lower right quadrant in place or planned.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the endosteal implant have been met. Therefore, we decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010) for tooth #19.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept intraosseous nerve ablation procedure.

You asked the Plan to pre-approve the requested service. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says there is lack of evidence to support the procedure over traditional treatment of chronic lumbar pain.

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 requested service. Our physician reviewer found that the enrollee presented with complaints of chronic axial lower back pain around the lumbosacral junction. She has failed more than 36 months of conservative treatment for the pain symptoms without much benefit. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There are also multiple plausible alternate pain generators, including associated with radiculopathy. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exceptional indication. Therefore, the request for Intracept procedure at L5 and S1 vertebral bodies 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 requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept intraosseous nerve ablation procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pre-approve a surgical procedure for isolation of tooth with rubber dam (D3910) and a canal preparation and fitting of preformed dowel or post (D3950).

You asked the Plan to pre-approve the surgical procedure and canal preparation and fitting. You say that you have an authorization for a root canal approved, but this procedure cannot be done without an operation. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 surgical procedure for isolation of tooth with rubber dam (D3910) and a canal preparation and fitting of preformed dowel or post (D3950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that you would prefer to have this device to manage your medical condition. The Plan denied your request. The Plan says the criteria for coverage have 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. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that you feel that this therapy is medically necessary. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is correct, because this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, and that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The enrollee receives staff support and has been instructed in proper positioning techniques. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray,
each additional intraoral periapical x-ray, bitewing x-rays, and preventive procedure provided on February 22,
2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, and
preventive procedure. You say that the representative at the clinic contacted the Plan to make sure the
procedures would be covered. The Plan denied your request. The Plan says services rendered by a provider
who is not in-network 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 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 periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, and preventive procedure provided on February 22, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has not been shown to be safe and effective in long term studies.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar interspinous process stabilization
distraction device.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; second level (List separately in
addition to code for primary procedure) (22870). You say that the enrollee has had 6 months of prior
conservative treatment without significant pain relief. The Plan denied your request. The Plan says published
studies do not demonstrate any long-term health outcome advantage with the use of the Vertiflex Superion
Interspinous Spacer device.

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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices remain experimental for use in spinal surgery. 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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar interspinous process stabilization distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two autogenous connective tissue graft procedures (D4273 x2) and non-intravenous conscious sedation (D9248).

You asked the Plan to pre-approve the autogenous connective tissue graft procedures and non-intravenous conscious sedation. You say that these services should be covered under your benefit package. The Plan denied your request. The Plan says these services are not covered under your benefit package.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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 two autogenous connective tissue graft procedures (D4273 x2) and non-intravenous conscious sedation (D9248).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of breast implant on same day of mastectomy (ie, immediate) (CPT code 19340-LT) and peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371-51-LT) provided to the enrollee on October 28, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 services. Our physician reviewer found the record indicates that the enrollee had a procedure on October 28, 2020. The operative note states the enrollee underwent removal of implant with left breast reconstruction. There is no documentation of a mastectomy being performed. CPT code 19340 is not recommended. The documentation indicates an implant was removed. CPT code 19371 is not properly billed in this case. CPT code 19371 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for insertion of breast implant on same day of mastectomy (ie, immediate) (CPT code 19340-LT) and peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371-51-LT) provided to the enrollee on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation procedure.
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested services have not been met.
The Plan follows Medicare rules. Medicare rules say that the enrollee must have had at least 80% pain relief from prior facet joint injections. 
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 lumbar facet joint radiofrequency ablation procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found this 80-year-old man has chronic low back pain. He is taking Norco for pain. He is seeing a Chiropractor for therapy and also has spinal stenosis. He underwent L3-L4, L4-L5 and L5-S1 facet injections and had 50% pain relief. In this case, the patient did not achieve 80% pain relief and therefore, another pain generator should be sought. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar facet joint radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation procedure.