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

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete 
series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on April 14, 2021 by an OON provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
prophylaxis. You say that you spoke with a Plan representative on March 8, 2021 and were advised that this 
treating provider was in-network with your plan. You also say this service should be covered because you are 
enrolled in the dental rider. The Plan denied your request. The Plan says these charges exceed the allowable 
amounts for these procedures. The Plan also says that during your call with the Plan you were advised of in-
network providers, but the provider you were treated by was not mentioned as 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, you are responsible for the difference 
between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan 
does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays 
(D0210), and prophylaxis (D1110) provided on April 14, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 is being treated for low
back pain and lumbar intervertebral disc degeneration. There are no recent objective exam findings in the
submitted records. Multiple other plausible pain generators are evident. Furthermore, the requested
flexion/extension x-rays were not provided to verify that the L4-5 spondylolisthesis noted on magnetic
resonance imaging (MRI) is stable. The records do not support that the Intracept procedure is reasonable and
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-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an office consultation with an out-of-network ophthalmologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is OK to be seen by a contracted cataract specialist.

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-approve a referral for an office consultation with an out-of-network ophthalmologist.
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 an IRF admission is medically necessary. The Plan
denied your request. The Plan says based upon Medicare guidelines, IRF care is not considered medically
reasonable or necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that this enrollee will be able to fully participate in and benefit from the 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95907, 95987) provided on February 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
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 95907 is "Nerve conduction studies; 1-2 studies". The
CPT Code Manual definition of code 95987 is "Needle electromyography, non-extremity (cranial nerve
supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately
in addition to code for primary procedure)".
We asked our coder 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 use of codes 95907
and 95987 is not supported by the records provided. Our reviewer found that the procedure report documents
"The surgeon stimulated areas of interest, and successfully identified the recurrent laryngeal nerve". The
documentation does not include enough information to confirm a nerve conduction study was performed.
CPT 95987 also would not be covered, which includes a nerve conduction study, which cannot be confirmed as
performed.
We looked at this coder'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 the services (95907, 95987) provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev.
You asked the Plan to pre-approve Ofev. You say that Ofev is indicated for the treatment of the enrollee's
condition. The Plan denied your request. The Plan says Ofev to be administered at home is not covered under
the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ofev.
Benefits for Ofev 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on May 6, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The services you asked the Plan to pay for are considered routine vision services or eyewear. Eye refractions are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says this request does not
meet the Plan's Part B step therapy criteria for the requested viscosupplement device.
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 Gelsyn-3. Our reviewer says that
Gelsyn-3 is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the
medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our
reviewer also found that based on the medical records provided there is no indication that the Plan's required
drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3 (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 7, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you are on Social Security and are unable to pay additional expenses. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 7, 2021.
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 you need inpatient rehab services. The Plan denied
your request. The Plan says criteria for admission to an IRF are not met. Your 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom manual wheelchair (K0005) with power assist system (E0986) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a group 2 powered wheelchair is the most appropriate item.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, a group 2 power wheelchair would be more appropriate for the enrollee's needs than the manual wheelchair with the power assist that was requested. 

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 pre-approve a custom manual wheelchair (K0005) with power assist system (E0986) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses (V2100, V2020, 92014).
You asked the Plan to pre-approve routine eyeglasses. You say that you had an eye injury that caused your vision to change and you require new glasses. The Plan denied your request. The Plan says you have exhausted your vision benefit this year and are not eligible for coverage of a new pair of eyeglasses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when once per plan year. We looked at the file and the Plan's rules. The Plan provided documentation showing that coverage was previously provided for routine eyeglasses on March 8, 2021. Based on this information, we determined that the Plan's routine eyewear benefit has been exhausted for the 2021 plan year. Therefore, we decided that the Plan does not have to pre-approve routine eyeglasses (V2100, V2020, 92014).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that you cannot walk without assistance or supervision. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued services. Our physician reviewer found that you are at a moderate assist level for propelling a wheelchair, and contact guard assist for navigating stairs. You do not have documented skilled nursing or skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on July 24, 2020.
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 Current Procedural Terminology (CPT) code 97110 GP CQ KX (4 units) remains not supported.
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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." We asked our coder 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 reviewer found the medical records document that service was performed in a home health or hospice setting. 97110 is not the most appropriate code to represent the service performed. There is a more appropriate Healthcare Common Procedure Coding System code to use to bill this service, therefore, this service is not eligible for reimbursement consideration.
We looked at this coder'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 physical therapy services (CPT 97110) provided to the enrollee on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95957) provided on October 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.

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 95957 is "Digital analysis of electroencephalogram
(EEG) (eg, for epileptic spike analysis)".

We asked our coder 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 use of code 95957 is
not supported by the records provided. Our reviewer found that the medical records provided do not include sufficient evidence to validate that a digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) was performed on October
5,2020. Therefore, this service cannot be verified.

We looked at this coder'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 the services (95957) provided on October 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Nurtec ODT for the enrollee.

Benefits for this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with a computerized knee, extra 
protective cover, and additional components (L5856, L5828, L5845, L5848) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason why a microprocessor knee would be medically necessary for the 
enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records from the prescribing provider do not clarify why a microprocessor K3 knee is required over a 
mechanical K3 knee. Medicare guidelines state that for coverage the item must be "one that meets, but does not 
exceed, the beneficiary's medical need." 
 
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 pre-approve a prosthetic leg with a computerized knee, extra protective cover, and additional 
components (L5856, L5828, L5845, L5848) for the enrollee.