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

We decided that the Plan does not have to pre-approve retainer crowns, porcelain fused to predominantly base metal (D6751) for teeth # 4, 5, 6, 13, and 14, and pontics, porcelain fused to predominantly base metal (D6241) for teeth # 7, 8, 9, 10, 11, and 12.
You asked the Plan to pre-approve the dental services. You say that last year you were suffering from an abscess in your gums due to teeth problems. You say that the implant doctor that you saw recommended implants. You say that implants are expensive and you would probably have the same issue again in 10 years. The Plan denied your request. The Plan says the requested dental services do not meet the expectation that the work would last at least 3 years.
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 services are not medically necessary. Our physician reviewer found the abutments for teeth #4, 5 and 14 would be virgin teeth, #6 and #13 had prior endodontics, and # 10 and #11 periodontally involved teeth will be extracted. There is no periodontal charting included with the record, only the full series of x-rays. The
request also includes two endodontically treated teeth, which are generally more prone to fracture. Therefore, although root surface analysis may show about equal root surface between the abutments and the missing teeth, there is unclear periodontal and the additional issue of two endodontically treated abutments with posts which weaken the overall prosthesis by having an increased risk of fracture. Fracture of either of these endodontically treated teeth would cause a failure of the entire bridge. The reviewer found that given the unclear periodontal support and the presence of two endodontically treated teeth with posts, long term stability of the prosthesis is uncertain. Therefore, the requested services would not be medical 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 retainer crowns, porcelain fused to predominantly base metal (D6751) for teeth # 4, 5, 6, 13, and 14, and pontics, porcelain fused to predominantly base metal (D6241) for teeth # 7, 8, 9, 10, 11, and 12.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide-Formoterol (Symbicort) for the enrollee.
You asked the Plan to pre-approve the requested drug. You say that the drug has helped, and you do not want to change. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide-Formoterol (Symbicort) for the enrollee.
Benefits for the requested drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a nuclear stress test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary for evaluation of progression of coronary artery disease. The Plan denied your request. The Plan says that the enrollee is asymptomatic.
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 the test. Our reviewer says that the requested test is considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the enrollee has known obstructive coronary disease (prior stent), a prior nuclear stress test on 11/15/2016 without ischemia, and no subsequent stress testing. In this circumstance of a clinically stable patient more than two years from the most recent stress test, a repeat nuclear stress test meets coverage criteria since one covered indication includes "Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT
perfusion imaging, who have not had a revascularization procedure within the past two years or greater than 2 years since last imaging study". 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 test have been met. Therefore, we decided that the Plan has to pre-approve a nuclear stress test for the enrollee.
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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the recent history reveals no reports of shortness of breath with exertion, or no symptoms suggestive of myocardial ischemia.
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 the imaging. Our reviewer says that the requested imaging is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has increased coronary risk from prior ST segment depression on stress testing more than two years ago, suggestive of ischemia. In this circumstance nuclear stress testing is reasonable for more accurate diagnosis of ischemia and to assess for potential progression of disease. Coverage criteria are met since one covered indication includes "risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease who have not had a revascularization procedure within the past two years".
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 imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a bed purchased from provider on February 19, 2019.You asked the Plan to pay for the bed. You say that this should be paid for.The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.This furniture company is not eligible to bill Medicare. The plan did not pre-approve the bed. 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 fora bed purchased from provider on February 19, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the interpretation of the abdominal x-ray (two views) provided on
October 31, 2019.
You asked the Plan to pay for the abdominal x-ray interpretation. You say that this was billed correctly for the
services rendered. The Plan denied your request. The Plan says that code 74019 is not payable since it was
billed on the same date as 74022.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the Plan has not submitted sufficient information to support that the
CPT code 74022 was billed for this date of service. The case file contains a claim for services provided, in which codes 70498 and 71045 were billed, which corresponds to a CT angiography of the neck and a
chest x-ray. The remittance advice shows that one of the line items was listed as 74022/71045. It is not clear
why this code was added to the remittance advice, as this is not listed on the claim image provided. In addition,
it is not appropriate for two codes to be listed on the same line item. The Plan's denial rationale is based on
code 74019 not being payable when billed on the same date as 74022. Without clear evidence that 74022 was
billed or that the services provided were indeed for a complete acute abdominal series plus one chest x-ray, we
find that the denial of payment of 74019 is not supported. Therefore, we decided that the Plan has to pay for the
interpretation of the abdominal x-ray (two views) provided on October 31, 2019.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a right reverse total shoulder arthroplasty for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has constant severe right shoulder pain with functional limitations in activities of daily living. Clinical exam findings have been consistent with imaging evidence of severe end-stage glenohumeral arthritis as well as complete, retracted tears of the supraspinatus and infraspinatus tendons, circumferential tearing and fraying of the labrum, retracted tear of the long head of the biceps tendon, and torn AC ligaments. She has failed to improve with activity modification, NSAIDs, and corticosteroid injection. Additional conservative treatment is not indicated in the setting of end-stage osteoarthritis and the severe shoulder pathology documented on imaging. The procedure is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a right reverse total shoulder arthroplasty for the enrollee.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for direct skilled nursing services by a registered nurse (RN) in a home health or hospice setting (G0299), and services performed by a qualified physical therapist in a home health or hospice setting (G0151) provided from July 2, 2019 to July 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for services performed in a home health or hospice setting. You say that you are the only provider in the area that accepts the plan and you have tried multiple times to become contracted again. You are asking the Plan for reconsideration and payment of the claim.The Plan denied your request. The Plan says It is the responsibility of the provider to contact the Health Plan regarding the requirements of the enrollee's plan. The services were not urgent or emergent in nature and the claim processed correctly.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 direct skilled nursing services by a registered nurse (RN) in a home health or hospice setting (G0299), and services performed by a qualified physical therapist in a home health or hospice setting (G0151) provided from July 2, 2019 to July 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve porcelain crowns with high gold content (D2750) for teeth # 18 and 19, the retainer crowns (D6740) for teeth # 28 and 31, and core build up (D2950) for teeth # 18, 19, and 31.
You asked the Plan to pre-approve the dental services. You say that you had a root canal. You say that now you need a crown. The Plan denied your request. The Plan says that the porcelain crowns are not covered due to subcrestal decay. The Plan says that core build up is not a covered service. The Plan also says that the retainer crowns 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 requested dental services are medically necessary. Our physician reviewer found due to the significant breakdown of teeth # 18, 19 and 31, core buildup (D2950) and crowns (D2750, D6740) are medically necessary. The bone support appears adequate and the caries does not appear to extend subcrestal. The replacement of extracted teeth # 29 and 30 meets the criteria for coverage for a fixed bridge using # 28 and 31 as abutment crowns (D6740). The reviewer also found that a fixed bridge would restore the masticatory function of the right side. Therefore, the requested dental services are medically reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve porcelain crowns with high gold content (D2750) for teeth # 18 and 19, the retainer crowns (D6740) for teeth # 28 and 31, and core build up (D2950) for teeth # 18, 19, and 31.
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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve nuclear myocardial perfusion imaging (MPI) stress testing for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that cardiac nuclear imaging is covered when specific criteria are met. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee is to undergo laparoscopic herniorrhaphy and was referred for stress testing. EKG stress testing was positive for coronary ischemia. She was referred for subsequent MPI stress testing to confirm the EKG stress findings. She has a number of risk factors for coronary artery disease. Further evaluation with MPI stress testing is medically necessary to assess the likelihood of clinical ischemia prior to undergoing the non-cardiac surgical procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve nuclear myocardial perfusion imaging (MPI) stress testing for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0481) provided on August 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for drug testing. You say that you agree that pre-authorization was required but you didn't acquire it because the member was visibly sick. It is a part of your oath to humanity, to service the patient regardless of authorization.The Plan denied your request. The Plan says services from non-participating providers are not covered under the member's plan unless they are authorized by the plan before the services are provided. A valid referral was not found on file for the service in question. The Health Plan does not deny the medical necessity of the services however, authorization was not obtained.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 drug testing (G0481) provided on August 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided in an outpatient hospital facility on August 6, 2018.
You asked the Plan to waive the copayment for wound debridement. You say that you disagree with the charges. 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  members must pay a $350 copayment for surgery services provided in an outpatient hospital facility. You received wound debridement on August 6, 2018. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $179.70, which is less than the $350 copayment. You have been asked to pay $179.70 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional ambulance miles provided on August 29, 2019.You asked the Plan to pay for the additional ambulance miles. The Plan denied your request. The Plan says that mileage is only covered to the nearest appropriate facility.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements.The services you have asked the plan to pay for are ambulance transport services beyond the distance to the nearest appropriate facility. This is not a covered benefit of Medicare or the health plan.Therefore, we decided that the Plan does not have to pay for the additional ambulance miles provided on August 29, 2019.