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

We decided that the Plan does not have to pay for the limited oral exam (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the extraction (D7210) provided on January 16, 2020.
You asked the Plan to pay for the dental services. You say that The Plan denied your request. The Plan says the services were billed incorrectly. The Plan says a corrected claim form was not received.
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes are listed as a requirement for claim forms to be valid. We looked at the file and Medicare rules. We found that no diagnosis code was reported on this claim. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the extraction (D7210) provided on January 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health nursing visits.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has met all of this homecare goals.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. The file shows that 5 home health skilled nursing visits were requested. The plan has agreed to pre-approve 3 visits. 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 2 visits. Our physician reviewer found that the enrollee was admitted to homecare for medical monitoring and management of a urinary tract infection. Ertapenem was given and the patient tolerated it well. Vital signs have remained stable, and he is taking medication as prescribed. The enrollee had no pain. He was educated on safety, medications, disease management, skin breakdown, diabetic management. The physician was notified of homecare discharge. The records do not show that skilled nursing services are required to effectively provide treatment, care, or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain his condition or prevent deterioration. The enrollee has been educated in disease management, safety, and has had stable medical conditions. Therefore, the enrollee does not have IV antibiotics or complex wound care or other skilled nursing need beyond what was authorized 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health treatment.You asked the Plan to pre-approveinpatient mental health treatment. You say that the services are necessary.The Plandenied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 inpatient mental health treatment. Our reviewer says that the requestedservices are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 1, 2020 forward. The enrollee could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute threats to safety with lessoned delusional thinking.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of inpatient mental health treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health treatment.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are currently bedbound after a leg amputation and cannot use the bathroom on your own. You are not able to afford these products and they are necessary for you. The Plan denied your request. The Plan says Medicare does not cover incontinence supplies.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided to February 7, 2019.
You asked the Plan to pay for the provided testing. You say that the testing helps distinguish patients at
increased risk for clinically significant prostate cancer. The Plan denied your request. The Plan says better
evidence is required to support the procedure.
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 provided testing. Our physician reviewer
found that the enrollee presented with an elevated prostate specific antigen (PSA). A Rectal exam revealed a
moderately enlarged, non-tender, firm prostate without nodules. A SelectMDx prostate cancer assay was
ordered to decide whether a prostate biopsy was needed. The documentation does not support that the prostate cancer assay was medically reasonable and necessary for the enrollee. The enrollee does
not have a diagnosis of newly diagnosed localized prostate cancer. The documentation does not support that the
assay was likely to impact a treatment decision in this case.
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 provided testing have not been met. Therefore, we decided that the Plan
does not have to pay for the  testing provided to February 7, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for additional sessions of psychotherapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says MFTs are not qualified Medicare providers, and cannot bill Medicare.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The referral cannot be fully approved as the requested provider is not eligible to bill Medicare. Based on this information, we decided that Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for additional sessions of psychotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a replacement of the right partial hand prosthesis (HCPCS L7499) for the enrollee.
You asked the Plan to pay for the prosthesis. You say that the current prosthesis is 2.5 years old and is in disrepair. The Plan denied your request. The Plan says the requested prostheses and components cannot be covered as the incorrect code is being used.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code L74999 is "upper extremity prosthesis, not otherwise specified." We find that HCPCS code L74999 is not supported in the medical record. Specifically, coding guidelines have stated that this code is not be used in this instance. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for a replacement of the right partial hand prosthesis (HCPCS L7499) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve primary closure of a sinus perforation (D7261), first 15 minutes of deep sedation/general anesthesia (D9222), and additional 15 minute increment of deep sedation/general anesthesia (D9223).
You asked the Plan to pre-approve the primary closure of a sinus perforation and deep sedation/general anesthesia services. You say that you were told that the sinus lift needed to be done before you can have your tooth extracted. The Plan denied your request. The Plan says these services 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve primary closure of a sinus perforation (D7261), first 15 minutes of deep sedation/general anesthesia (D9222), and additional 15 minute increment of deep sedation/general anesthesia (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on February 7, 2020. You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the charges because you have never been charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $40 copayment for an eye exam. An eye exam falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist services. You say that you would like to use an out-of-network provider for these services.The Plan denied your request. The Plan says they will not refer the member to a non-Plan provider because there is no medical indication to do so as services are available in-Plan.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-approvespecialist 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 crown and core buildup, including any pins when required.
You asked the Plan to pre-approve the crown and core buildup. You say that tooth #19 has existing DO resin leaking, with recurrent decay on occlusal and initial mesial decay and undermined distal cusps. 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 crown and core buildup, including any pins when required.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio (Q5101).You asked the Plan to pre-approveZarxio. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Zarxio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Neupogen (Filgrastim) and Nivestym (Filgrastim-aafi) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio (Q5101).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you have been seeing the provider for continuing throat problems. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider without 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Aranesp injection,25mcg/.42 ml every 2 weeks.You asked the Plan to pre-approvethe Aransesp injection. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says medical necessity and step therapy criteria must be met in order for the requested drug to be covered. The Plan also says documentation supporting the medical necessity for a step therapy exception was not received.Medicare covers Part B medications when they are reasonable and necessary but allows health plansto 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 the Aransesp injection. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the documentation that was submitted does not support that the enrollee has had prior treatment, contraindication, or intolerance to Retacrit. The reviewer found no reason why the alternative Retacrit required by the Plan would not be as effective for the enrollee as the requested drug; and/or would have adverse effects for the enrollee. The reviewer found that an exception to these criteria is not supported and therefore is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the Aransesp injection have not been met.Therefore, we decided that the Plan does not have to pre-approvean Aranesp injection, 25mcg/.42 ml every 2 weeks.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing home health visits (G0162 and G0299).
You asked the Plan to pre-approve skilled nursing home health visits. You say that you need these services.
The Plan denied your request. The Plan says the records do not show that you are homebound and in need of
skilled services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 skilled nursing home health visits. Our
reviewer says that the criteria for coverage of home health services have not been met. Our physician reviewer
found the documentation does not clearly reveal that you are homebound with leaving the home being a
significant and taxing effort. Furthermore, the documentation does not reveal complex wound care, new enteral
feeding or other skilled nursing needs. The request is for a home health nurse you as you are unable to
independently perform several activities of daily living such as showering, cooking and toileting would not be
considered skilled nursing 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 skilled nursing home health visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing home health visits (G0162 and G0299).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that you can barely walk. The Plan denied your request. The Plan says that you have not tried and failed conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found that the enrollee has long standing lower extremity pain from the hips down the legs for years, which has worsened, and has significantly impacted the enrollee's functional status. The records indicate that the enrollee has been diagnosed with diabetic neuropathy, as well as lumbago with sciatica on the left side, which was treated with an injection of Dexamethasone. The enrollee has also been treated with Gabapentin. The enrollee had an initial evaluation by the pain management specialist on April 22, 2020, who has indicated that the enrollee's significant pain could be radicular in nature, and is also likely to be neuropathic related to diabetes mellitus. Based on a review of the submitted medical records, and the rules, the requested MRI of the lumbar spine is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.