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

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp vitality tests (D0460), problem focused limited oral evaluation (D0140), or pay more for the endodontic therapy (D3320) provided on January 19, 2021, and February 12, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, problem focused limited oral evaluation, and to pay more for the endodontic therapy. You say that you would like these services to be covered in full. The Plan denied your request. The Plan says the cone beam CT capture and interpretation and pulp vitality tests are not covered benefits under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan, and you were correctly assessed a coinsurance of $413.50 for the endodontic therapy.

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 cone beam CT capture and interpretation (D0364) and pulp vitality tests (D0460) are not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 11, 2021, and your problem focused limited oral evaluation (D0140) benefit has been exhausted. The Plan contract also says that you must pay a 50% coinsurance for endodontic therapy (D3320). Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp vitality tests (D0460), problem focused limited oral evaluation (D0140), or pay more for the endodontic therapy (D3320) provided on January 19, 2021, and February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of peripheral nerve neurostimulator electrode through skin (64555) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the insertion of peripheral nerve neurostimulator electrode through skin. You say that this service can only be provided by an OON provider. The Plan denied your request. The Plan says in-network providers are available to provide the enrollee with this service.

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 provider at issue in this case is not a network provider with the Plan. 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 insertion of peripheral nerve neurostimulator electrode through skin. Our reviewer says that the requested service does not need to be provided by an OON provider.

Our physician reviewer found that the enrollee is a 69-year-old male with chronic pain who is requesting authorization for consideration for in-network benefit level for a peripheral nerve stimulator surgery at an out of network provider. There is no specific clinical rationale for the out of network provider. The documentation indicates that services are available with plan providers. The review has determined that it is not medically necessary that this procedure be provided at the OON facility with the enrollee's transplant team available.

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 insertion of peripheral nerve neurostimulator electrode through skin have not been met. 

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 the insertion of peripheral nerve neurostimulator electrode through skin. Therefore, we decided that the Plan does not have to pre-approve the insertion of peripheral nerve neurostimulator electrode through skin (64555) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 106 PT visits.
You asked the Plan to pre-approve an additional 106 PT visits. You say that the member is paraplegic and has regressed in recovery and after physician assessment, it was concluded that member could participate in therapy services. You say that it would be detrimental for the member unless continued care is provided under the supervision of a skilled physical therapist. The Plan denied your request. The Plan says upon completion of the additional 12 PT visits that are approved at this time, the enrollee will no longer meet medical necessity criteria for continuation outpatient physical therapy services.
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 an additional 106 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior extensive therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist 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 an additional 106 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 106 PT visits.
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 the enrollee has tried multiple oral medications. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug and zoledronic acid before they will approve the requested drug. The enrollee has tried and failed oral bisphosphonates, but the prescriber has not provided a sufficient medical rationale why zoledronic acid would not be appropriate 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure described by current procedural terminology (CPT) code 22842 provided on December 2, 2020.

You asked the Plan to pay for CPT code 22842. You say that the medical records support the billing of CPT code 22842. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 22842.

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 22842 is Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (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 CPT code 22842. Our reviewer says that the medical records do not support the billing of CPT code 22842. Our physician reviewer found in this case; the operative note does not describe posterior segmental instrumentation including fixation. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 22842 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure described by current procedural terminology (CPT) code 22842 provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 1 power wheelchair.

You asked the Plan to pre-approve the group 1 power wheelchair. You say that you would like reconsideration because you recently had a hip replacement and are unable to walk. The Plan denied your request. The Plan says there is insufficient information to determine if medical necessity criteria have been met.

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 group 1 power wheelchair. Our reviewer says that the documentation is not clear that your mobility limitation significantly impairs your ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

The documentation does not reveal that your mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane, manual wheelchair or walker. Our physician reviewer found the documentation does not reveal that your home provides adequate access for the requested wheelchair and that the use of the wheelchair will significantly improve your mobility-related activities of daily living.

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 group 1 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 1 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on January 12, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, an intraoral complete series of radiographic images, and an unspecified preventive procedure. You say that you were unable to obtain the previous radiographic images you had done, so new ones had to be taken. You want the Plan to pay for the services at issue. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The intraoral complete series of radiographic images is a covered benefit, but you have exceeded the frequency limit of one every 5 years. An unspecified preventive procedure 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, an intraoral complete series of radiographic images, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on July 23, 2019. Additionally, an unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided by an out-of-network provider on
February 3, 2021.

You asked the Plan to pay for the mammogram. You say that the doctor's office representative noted it was ok
to see the doctor. You say that you would never had gone if you were told the doctor was not in-network. The
Plan denied your request. The Plan says this provider is not a network provider with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 had network providers
available who could have provided 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 mammogram provided by an out-of-network
provider on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on September 22, 2020.

You asked the Plan to waive the copay for the services provided. You say that you were never billed for lab services. The Plan denied your request. The Plan says the copay was applied appropriately.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copay for lab services in an outpatient hospital. 

You have been asked to pay $11.26 for the services provided. Because the amount is less than the $15 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the lab services provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating
provider on November 30, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10%
coinsurance for Part B drugs.

You have been asked to pay a 10% coinsurance of the allowed amount for an injection. The total allowed
amount is $79.24. The total amount you are being asked to pay is $7.92 ($79.24 x 10% = $7.29). The correct
coinsurance has been applied to the services that were provided. An injection falls within the Part B drugs
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 coinsurance for an injection provided by a
participating provider on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve a CGM and related supplies. You say that the records provided support the need for a CGM and related supplies. The Plan denied your request. The Plan says there is no indication that the enrollee measures his blood sugars at least 4 times a day. The Plan says that the enrollee is not receiving insulin injections at least 3 times a day. The Plan says that the enrollee is not undergoing frequent changes to his insulin dose.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and related supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found while the enrollee is adjusting the basal insulin dose, he is not taking the required 3 shots of insulin per day. Our physician reviewer found that the records provided do not explain why glucometer testing would not suffice for this 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 a CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve janus kinase 2 (JAK2) gene analysis (81270), molecular pathology procedure levels 3, 4 (81403) and CALR mutation analysis (81219).

You asked the Plan to pre-approve the laboratory services. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says the medical records received from the provider did not indicate how the results of this testing will change the members treatment.

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 laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this has been a chronic process since 2016 and there has been a negative workup in the past. 

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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve janus kinase 2 (JAK2) gene analysis (81270), molecular pathology procedure levels 3, 4 (81403) and CALR mutation analysis (81219).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the ability drive interface, hardware and software, the Mount N'
Mover Mounting Kit, 18" Post for Permobil, the ability drive joystick 13" tablet computer with gaze, the ability
drive power smart power, the eye tracking system with Tobii Technology, Windows, and the Smartbox Grid 3.

You asked the Plan to pre-approve the remaining accessories. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.

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. Specifically, it is the plan's responsibility to show that its decision to deny
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's
failure to obtain records that are within the plan's control. The plan did not provide any medical records in
order to determine if the enrollee meets Medicare criteria for the requested power wheelchair repairs and
accessories.

Furthermore, the case file the Plan sent contains no documentation to verify what the appellant is requesting.
The Plan's final determination letter says that requested paint is not covered; however, there is no
documentation in the case file showing that paint has been requested. The case file the Plan provided is
incomplete and there is not enough information provided to substantiate the Plan's reasoning for denial.
Therefore, we decided that the Plan has to pre-approve the ability drive interface, hardware and software, the
Mount N' Mover Mounting Kit, 18" Post for Permobil, the ability drive joystick 13" tablet computer with gaze,
the ability drive power smart power, the eye tracking system with Tobii Technology, Windows, and the
Smartbox Grid 3.

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.