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

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on January 26, 2021.
You asked the Plan to pay for the pulp vitality tests. You say that your office was told that the endodontic therapy (D3320) was covered at 100%. You also say that you were misquoted during your initial call with the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's 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 pulp vitality tests (D0460) provided on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are not receiving active treatment nor is active treatment considered to be of likely clinical benefit for you.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you are not showing any dangerousness to self or others, auditory or visual hallucinations and are without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. 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 psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Renflexis (Q5104).
You asked the Plan to pre-approve Renflexis. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment 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 Renflexis. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the record indicates that the enrollee has rheumatoid arthritis. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Renflexis (Q5104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a light therapy system (E0694).

You asked the Plan to pre-approve a light therapy system. You say that this is medically necessary. The Plan denied your request. The Plan says this is only supported for psoriasis.

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 a light therapy system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found your diagnosis has not be established by a biopsy. The submitted records also do not document reasoning that an in-office unit cannot be used. 

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 light therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve a light therapy system (E0694).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require and skilled nursing services and you do not require skilled therapy services on a daily basis or at an inpatient level in a SNF. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. THis means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of August 24, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for continued inpatient level of care is correct, because you can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 psychiatric care. Our reviewer says that you do not meet the Medicare criteria for inpatient psychiatric care. Our physician reviewer found it is not expected that you will improve in a reasonable period of time as of August 24, 2021, as you do not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for trigeminal division block anesthesia (D9212) provided on April 8, 2021.

You asked the Plan to pay for trigeminal division block anesthesia (D9212). You say that the dentist advised the work is not cosmetic and is necessary for good oral health. You say that you don't understand the denial for the anesthesia. The Plan denied your request. The Plan says the service 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 pay for trigeminal division block anesthesia (D9212) provided on April 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this type of surgery is considered experimental and/or unproven.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Multiple other plausible pain generators including at the lumbosacral spine are evident. In addition, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept procedure, intraosseous ablation of basivertebral nerve 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require any skilled nursing services and you do not require skilled therapy services on a daily basis or at an inpatient level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that the enrollee's pain is getting bad. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee in this case. The enrollee has right shoulder pain from osteoarthritis who is undergoing an elective non-emergent right reverse total shoulder arthroplasty. The enrollee's past medical history was significant for hypertension, neuropathy, gastroesophageal reflux disease and breast cancer in remission. There was no indication from the recent documentation that the patient would require hospital services that would likely cross 2 midnights for this lower risk procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services. 

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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on April 27, 2021.
You asked the Plan to pay for the full mouth debridement. You say that you got a more extended cleaning but the normal coverage for the cleaning should also apply for this cleaning. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 full mouth debridement (D4355) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture provided on May 26, 2021.

You asked the Plan to pay for the complete upper denture. You say that you were not aware you had a $1,000 annual maximum and the claim should be overturned. The Plan denied your request. The Plan says your yearly maximum has been reached.

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 also have a maximum benefit of $1,000 per calendar year for in and out-of-network services. The Plan paid $1,000 toward the dental services received on May 18, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for (2) two office visits (99213) provided on May 3, 2019, to August 7, 2019, by an out-of-network (OON) provider.
You asked the Plan to pay for office visits. You say that you do not need a referral for the member's Plan. You also say that you would like the claim reprocessed and paid accordingly. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 (2) two office visits (99213) provided on May 3, 2019, to August 7, 2019, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed side rails.

You asked the Plan to pre-approve the bed side rails. You say that the bed side rails are 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 bed side rails are a covered benefit if required by the beneficiary's condition AND they are an integral part of, or an accessory to, a covered hospital bed. 

We looked at the file and Medicare rules. The rails requested are not a part of or accessory to a covered hospital bed. Based on this information, we decided that Medicare rules for coverage of the bed side rails have not been met. Therefore, we decided that the Plan does not have to pre-approve bed side rails.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 20, 2019.
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 procedure code 15946 is 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 15946 is excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure. We find that CPT code 15946 is not supported in the medical record. Specifically, the records show that preparation for muscle or myocutaneous flap was not performed. There is a more appropriate code for the documented services. 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 surgical services rendered on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown fused to predominantly base metal (D2751).
You asked the Plan to pre-approve a porcelain crown fused to predominantly base metal. You say that you need this dental procedure performed because you are currently in pain. The Plan denied your request. The Plan says the benefit for this procedure 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 a porcelain crown fused to predominantly base metal once every 60 months.
We looked at the file and Medicare rules. In this case, the procedure was performed within the past 60 months on the same tooth. Based on this information, we decided that the Plan's rules for coverage of a porcelain crown fused to predominantly base metal have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown fused to predominantly base metal (D2751).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like reconsideration because the requested medical nutrition therapy is medically necessary. The Plan denied your request. The Plan says there is no physician order.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.
We looked at your request, the file and Medicare rules. Based on this information we have decided that coverage criteria for the requested service have not been met. Specifically, the record does not include a physician order for the Medical Nutrition Therapy. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with a Medical Weight Loss Clinic (protein drinks, food, check-ups, and weight check).
You asked the Plan to pre-approve medical nutrition therapy services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that you suffer from renal disease or diabetes. Nutritional supplements are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve services with a Medical Weight Loss Clinic (protein drinks, food, check-ups, and weight check).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for dermatology services provided on April 8, 2021.

You asked the Plan to reimburse you for the dermatology services. You say that you pay for insurance and you pay the doctor so the Plan should reimburse you. The Plan denied your request. The Plan says an opt-out provider cannot bill us nor can we pay you for these services.

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 dermatology services provided on April 8, 2021.