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

We decided that the Plan does not have to pay for the panoramic x-ray and periodontal maintenance provided 
on July 13, 2020. 
 
You asked the Plan to pay for the panoramic x-ray and periodontal maintenance. You say that you thought you 
were receiving a routine cleaning and bitewing x-rays. You also say that the provider did not advise that you 
were receiving these types of services, nor that they were not covered under your plan. 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. The contract clearly states that other periodontal services are not 
covered, and only lists bitewing x-rays as a covered benefit. The records show that the Plan contacted your 
provider who indicated you were due for full mouth x-rays, which is why the panoramic x-ray was performed. 
Your provider also said that you usually receive periodontal maintenance procedures and do not receive regular 
cleanings. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and periodontal 
maintenance provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 88341) provided to the enrollee on August 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the type 1 add-on code 88342 was billed with an acceptable primary procedure code which is not eligible for payment to the same practitioner for the same patient on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88341 is "Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)." 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 reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the case file does not contain clinical records. The documentation in the case file does not support the coding of CPT 88341. 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 laboratory services (CPT 88341) provided to the enrollee on August 8, 2019.
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 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you rendered medically necessary services in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) 
provided on May 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the consultation (D9310) and root canal (D3330) 
provided. 
 
You asked the Plan to reimburse you for the dental services. You say that based on the plan website, the closest 
in network dental provider is 100 miles away. You also say that when you called a plan provider, they were 
only interested in selling you implants. The Plan denied your request. The Plan says the provider in this case is 
not a network provider. The Plan says that dental services that you receive out of network are not covered. The 
Plan also says that the services you received 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services that you received 
are not covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
consultation (D9310) and root canal (D3330) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forunclassified drugs provided on May 12, 2020.You asked the Plan to pay forunclassified drugs. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the medical records indicate that a drug in compounding form was administered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Healthcare Common Procedure Coding System (HCPCS) code J3490-(1 unit) remains not supported. Healthcare Common Procedure Coding System (HCPCS) code J3490 represents unclassified drugs. The medical records indicate that drug in compounding form was administered. There is a more appropriate HCPCS code, J7999, that should be used to bill for drugs that are administered in compound form. Therefore, the billed Healthcare Common Procedure Coding System (HCPCS) code, units and modifier cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentationto corroborate the services so we can confirm Medicare coverage has been met.Therefore, we decided that the Plan does not have to pay forunclassified drugs provided on May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the lumbar spine (72158).You asked the Plan to pre-approvethis service. You say that an MRI of the lumbar spine is medically necessary.The Plan denied your request. The Plan says that an MRI of the lumbar spine is not medically necessary.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 denyingthe request to pre-approve this service. Our reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the enrollee has recently undergone an L5-S1 posterior lumbar interbody fusion with low back pain. Thesite of the procedure hadminimal drainage. A follow-up visit reported the wound getting smaller. The MRI of the lumbar spine has been requested to be able to know the depth of the wound dehiscence. There is no clinical rationale for the requested MRI. Per the reviewed documentation, the wound is described as closing and healing, an ultrasound to attempt the same measurement in a safer fashion has not already been documented, and an MRI generally lacks additional sensitivity for superficial skin structures. The review has determined that the requested MRI 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the lumbar spine (72158)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says documentation was not received addressing the step therapy criteria. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to 
have osteoporosis based on a June 2019 bone density test. There is no documentation of a concomitant fracture. 

A request has been made to "start" the enrollee on Prolia. There is no evidence that the enrollee has tried, not 
responded to or been intolerant of zoledronic acid. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wireless capsule endoscopy.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a colonoscopy on July 14, 2020 showed hemorrhoids, sigmoid diverticulosis, patchy areas of colonic friability, and multiple terminal ileal ulcers. Histologyidentified active ileitis with ulceration, no granulomas. Wireless capsule endoscopy (WCE) has been proposed to assess for small bowel bleeding and enteritis. There is no documentation of a recently completed upper endoscopy, colonoscopy-evidence ileitis,or a preliminary small bowel follow-through. The WCE is therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea wireless capsule endoscopy.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for treatment of a broken wrist and a broken hip after a fall. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power operated vehicle (scooter) (E1230).
You asked the Plan to pre-approve the power operated vehicle. You say that you need a heavy duty power
wheelchair. You are fully dependent on the wheelchair. You've had your current one for 3 years but it is in bad
condition and broken down. The Plan denied your request. The Plan says the enrollee does not meet the
Medicare criteria for a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power operated vehicle. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not reveal that the enrollee has a personal mobility
deficit that impairs participation in MRADLs in the home. The documentation does not clearly reveal why the
enrollee's mobility deficit is currently unable to be helped by a cane, manual wheelchair, or walker. The
documentation does not reveal that the enrollee can safely maneuver the power mobility scooter in the home.
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 power operated vehicle have not been met. Therefore, we decided that the
Plan does not have to pre-approve the power operated vehicle (scooter) (E1230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2740) and core build up (D2950) 
provided on June 3, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were never advised that the 
provider had opted out of Medicare. You also say that you were under the assumption that these services would 
be covered under your dental plan. The Plan denied your request. The Plan says the provider in this case has 
opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive 
from a dental provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the crown (D2740) and core build up (D2950) provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require a transfer to a LTACH.
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 the enrollee does not require services at the LTACH that are not already available at the current setting. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current setting. Our physician reviewer also found that transfer to a lower level of care may be considered as soon as is appropriate. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient admission.
You asked the Plan to pre-approve inpatient admission. You say that the services are necessary. The Plan
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria
has not been met.
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 inpatient admission. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has sufficient diagnoses (acute renal failure, coagulopathy while being a fall risk,
rib fractures) that warrant admission. Therapy with agents that increase bleeding risk need to be reevaluated
prior to discharge. With being a fall risk, complications of falling are greater with the enrollee's coagulopathy.
Admission 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 inpatient admission have been met. Therefore, we decided that the Plan has to
pre-approve inpatient admission.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits.
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says the PT services
are 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 the PT visits. 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 that the requested additional therapy is not generally accepted as
specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this
condition and it does not appear that the enrollee requires the ongoing unique skills of a professional therapist
to safely and effectively provide treatment, or that the services can be safely and effectively performed only by
a therapist, or under the supervision of a therapist. The enrollee has been educated in her diagnosis and has a
good understanding of activity and instruction. The specialized skill, knowledge and judgment of a qualified
therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional inpatient mental health services for the enrollee.You asked the Plan to pre-approvethe additional services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has utilized the maximum Medicare 190-day lifetime freestanding psychiatric hospital benefit.The Plan must follow Medicare rules. Therules say that there is a 190 day lifetime for inpatient psychiatric hospital services.The file shows that 190 day lifetime limit has been met. Based on this information, we decided that Medicare rules for coverage of the additional services have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional inpatient mental health services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe screening DEXA scan interpretation provided on June 16, 2020.You asked the Plan to pay forthe screening DEXA scan interpretation. You say that the Plan should pay this claim.The Plandenied your request. The Plan says screening bone mass studies are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the screening DEXA scan study, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe screening DEXA scan interpretation provided on June 16, 2020.