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

We decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided on September 29, 2020.

You asked the Plan to pay for the dental services. You say that having a root canal was not a choice or a cosmetic procedure. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that the requested continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says that the requested continuous glucose monitor is not covered because there are no notes showing you have seen your diabetes doctor in the past 6 months to manage your diabetes.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee has a diagnosis of diabetes mellitus, the enrollee has been using a blood glucose monitor and has been performing frequent (four or more times a day) testing, the enrollee is insulin-treated with multiple (three or more) daily injections of insulin, and the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the basis of blood glucose monitor or continuous glucose monitor testing results. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93010, 99291) provided August 27, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 93010 & 99291 are not supported in the medical record. Specifically, the diagnosis code listed is not a valid primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (93010, 99291) provided August 27, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder TM test (blood test for cancer markers) (CPT Code 0012M) provided to the enrollee by a non-participating provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this test is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Your request is not a covered benefit because this test has been determined not to be clinically valid and is a non-covered test. Therefore, we decided that the Plan does not have to pay for the CxBladder TM test (blood test for cancer markers) (CPT Code 0012M) provided to the enrollee by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures.

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 dentures once every five years. 

Dentures were last received less than five years ago on August 12, 2019. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings for the blood circulation in your calves and feet. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because these compression stockings are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a dental crown for tooth #31 (D2752).

You asked the Plan to pre-approve a dental crown for tooth #31 (D2752). You say that the requested dental crown on tooth # 31 is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested dental crown for tooth #31.

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 a dental crown for tooth #31 (D2752) 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 a dental crown for tooth #31 (D2752). Our reviewer says that the requested dental crown meets the Plan's benefit criteria. Our physician reviewer found a review of the enrollee's dental record and radiographs indicates the presence of a large restoration and as noted in the record a fracture of the mesio-lingual cusp. A crown restoration to return the tooth to good masticatory function is reasonable and necessary. 

Due to the large restoration and fractured cusp, the Plan's criteria for coverage for a crown (D2752) for tooth #31 have been met. 

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 a dental crown for tooth #31 (D2752) have been met. Therefore, we decided that the Plan has to pre-approve a dental crown for tooth #31 (D2752).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on July 24, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for this service was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the Life2000 Ventilation System is considered not medically necessary. This system is not a true ventilator. It is a portable positive pressure device to be used during ambulation. There are insufficient data indicating the effectiveness of this device in treating COPD. The records do not include pulmonary function data or evidence of CO2 retention, so the enrollee does not meet coverage criteria for nocturnal BiPAP. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor.

You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that for a Continuous Glucose Monitor to be covered the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin. 

We looked at the file and Medicare rules. The record does not show that the enrollee uses three or more daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this will help prevent falls. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy with dental code D3320.

You asked the Plan to pre-approve dental code D3320. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D3320 is not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D3320 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy with dental code D3320.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology consultation services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON neurology consultation services. You say that you would like guidance on whether or not your family has a gene defect and on your next steps. You say that your family lost your mother due to ALS and have a brother who was recently diagnosed. You say that the requested OON provider is trying to establish how steady the ALS issues are within your family. The Plan denied your request. The Plan says the services being requested are available in-network.

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 neurology consultation services with the requested OON provider. Therefore, we decided that the Plan does not have to pre-approve neurology consultation 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 dental services (D6241, D6751) 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 this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D6241, D6751) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says no medical records were provided to support medical necessity.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We looked at the file and Medicare rules. Review of the file shows that medical records were not provided to support that the enrollee has a diagnosis that meets criteria for the requested drug. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia 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 moderate sedation services rendered on September 8, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Payment is included in the payment to the facility. 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 pay for the moderate sedation services rendered on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive periodontal evaluation with dental code D0180 and crown lengthening with dental code D4249.

You asked the Plan to pre-approve dental codes D0180 and D4249. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D0180 and D4249 are not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D0180 and D4249 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the comprehensive periodontal evaluation with dental code D0180 and crown lengthening with dental code D4249.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to 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 requested provider is no longer in-network.

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 to an out-of-network ophthalmologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Monovisc and Orthovisc.

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 Synvisc-One (J7325). 

Our reviewer says that the drug is not reasonable or medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drugs. 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 patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Xgeva (J0897).

You asked the Plan to provide Xgeva (J0897). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 provide Xgeva (J0897). Our reviewer says that the drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved drug compendia there is no documentation that Xgeva is FDA-approved for the enrollee's diagnosis of age-related osteoporosis without current pathologic fracture. The Medicare-approved drug compendia there no documentation to support the use of Xgeva for age-related osteoporosis without current pathologic fracture. The use of Xgeva for age-related osteoporosis without current pathologic fracture is not indicated, supported or recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee's age-related osteoporosis without current pathologic fracture.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva (J0897) have not been met. Therefore, we decided that the Plan does not have to provide Xgeva (J0897).