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

We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (SPECT).
You asked the Plan to pre-approve a myocardial perfusion imaging (SPECT). You say that the requested myocardial perfusion imaging (SPECT) is medically necessary. The Plan denied your request. The Plan says the requested myocardial perfusion imaging (SPECT) 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 myocardial perfusion imaging (SPECT). Our reviewer says that the requested myocardial perfusion imaging (SPECT) is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, hyperlipidemia, carotid intimal thickening, breast cancer, murmur and shoulder replacement. A nuclear stress test 10/09/2017 reported no ischemia and normal LV function. An echocardiogram 10/10/2017 reported normal ventricular function. A note dated 07/06/2020 reports no cardiac symptoms and scheduled for eyelid surgery. An electrocardiogram did not report any ischemic changes. Based on the records the enrollee has no cardiac symptoms, no ischemic ECG changes and no ischemia on prior stress testing scheduled for low risk non-cardiac eyelid surgery. In this circumstance the records do not support the medical necessity for nuclear stress testing. Coverage criteria are not met since there are no covered indications for the procedure. Stress testing is not recommended in stable patients prior to low risk non-cardiac surgery. 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 myocardial perfusion imaging (SPECT) have not been met. Therefore, we decided that the Plan does not have to pre-approve a myocardial perfusion imaging (SPECT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial denture (D5213).
You asked the Plan to pre-approve the dental services. You say that you believe the partial should be clamped
onto the remaining teeth. The Plan denied your request. The Plan says this service is not medically necessary as
there is not enough bone to support a partial.
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 requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the remaining three teeth in the upper arch have at least 50-75% bone loss due to
severe periodontal disease. A cast base partial denture is considered a tooth borne appliance, meaning
substantial forces are placed on the remaining teeth. Cast base partial dentures would require abutment teeth
with more than 50% remaining bone and minimal to no mobility to allow such an appliance to function
properly. In this case, the teeth are so compromised that they would quickly fail with the additional forces that
would be place on them with the use of such an appliance.
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 upper partial denture (D5213).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on May 8, 2018.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by a network provider with the Plan or through arrangements made by the Plan.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on May 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on May 4, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you are unable to work to pay the
copayment. The Plan denied your request. The Plan says the copayment applied correctly.
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 $30 per
visit for a specialist.
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Doctor
Visits" 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 the office visit provided on May
4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBrovana for the enrollee.You asked the Plan to pre-approveBrovana. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Brovana. Our reviewer says that Brovana is not medically reasonable and necessary for the enrollee in this case. There is no indication that the enrollee has tried and failed Perforomist or that it would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Brovana.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 3, 2020.You asked the Plan to waive the copayment for the laboratory work. You say that you should not be charged the copayment because the specimen was too small. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received the lab test.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 the laboratory work provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Reader and Sensor, for the enrollee.You asked the Plan to pre-approvethe DME. You say that the service is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You must be using a Blood Glucose Monitor or Continuous Glucose Monitoring System and testing four or more times a day.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Reader and Sensor, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on March 2, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you are not responsible for this bill because you are on Medicaid. The Plan denied your request. The Plan says periodontal maintenance 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 the periodontal maintenance provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth #10 (D2750).
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied your request. The Plan says the records do not support the need for a crown.
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 crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the documentation provided does not indicate that tooth #10 has a significant coronal breakdown due to caries or fracture to meet the criteria for restoration with a crown. 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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental crown for tooth #10 (D2750).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77061) provided on
February 24, 2020.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77061
has a status code of I which is not valid for Medicare purposes.
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 find that CPT code 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 77061 has a status code of I. This means that CPT code 77061 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis
have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast
tomosynthesis (77061) provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve standard wheelchair (K0001), for the enrollee.You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Since the initial request came in the member has been scheduled for surgery. Information on post-operative needs and if the member continues to require a wheelchair was not provided, so medical necessity for the requested DME cannot be determined.Therefore, we decided that the Plan does not have to pre-approve standard wheelchair (K0001), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture and complete maxillary denture provided on February 28, 2020 by an OON provider.You asked the Plan to pay for the complete mandibular and maxillary dentures. You say that your dentures cracked and broke, and the provider who rendered the services had the soonest availability and was cheaper. You also say that you feel the services were an emergency because you could not chew or eat.The Plan denied your request. The Plan says the services were rendered by an OON provider.  The Plan also says that although the services are covered under the Plan, you must see an in-network provider.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. The records show that you were not given this provider's information by a Plan representative, and self-referred to this OON provider.Therefore, we decided that the Plan does not have to pay for the complete mandibular denture and complete maxillary denture provided on February 28, 2020 by an 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 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 in this case, ongoing care needs includes respiratory support with oxygen supplementation, surveillance laboratory studies, anticoagulation, 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 30, 2019.You asked the Plan to pay for drug tests. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the codes billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on April 30, 2019.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does
not currently require intensive physician and nursing oversight only in an IRF. The documentation does not
support that your functional status requires an intensive rehabilitation therapy program provided in an IRF.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a myocardial perfusion imaging (SPECT).You asked the Plan to pre-approve a myocardial perfusion imaging (SPECT). You say that the requested myocardial perfusion imaging (SPECT) is medically necessary.The Plan denied your request. The Plan says that the requested myocardial perfusion imaging (SPECT) is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a myocardial perfusion imaging (SPECT). Our reviewer says that the requested myocardial perfusion imaging (SPECT) is medically necessary. Our physician reviewer found the enrollee is with a history of atrial fibrillation. An EKG in June, 2020 showed a right bundle branch block and left anterior hemiblock. A holter monitor, an echocardiogram, and a myocardial perfusion (SPECT) imaging multiple studies at rest and/or stress were ordered.The enrollee's heart rate has gone up to 200 during exercise. His ECG has a right bundle branch block and left anterior hemiblock, which make the ECG difficult to interpret. The enrollee has paroxysmal atrial fibrillation. SPECT MPI is not covered in patients with low pretest probability, an interpretable ECG, and the ability to exercise. In this case, the enrollee has a covered indication for myocardial perfusion (SPECT) imaging.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 myocardial perfusion imaging (SPECT) have been met.Therefore, we decided that the Plan has to pre-approve a myocardial perfusion imaging (SPECT).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 11, 2019.You asked the Plan to pay for the domiciliary, rest home visit. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 11, 2019.