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

We decided that the Plan does not have to pre-approvea consultation and root canal to be performed by an endodontist.You asked the Plan to pre-approvethe consultation and root canal. You say that you are in pain, and were advised that you need these services to be performed by an endodontist.The Plan denied your request. The Plan says there is no benefit for a root canal. The Plan also says that services performed by an endodontist are not covered because your dental benefits are limited to services performed by a participating general dentist.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, root canals are not among those covered under this benefit. The contract also says that covered services must be performed by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvea consultation and root canal to be performed by an endodontist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic PGxOne Plus panel (81225, 81226, 81230, 81231, 81240, 81241, 81328, 81408) provided on July 2, 2020.
You asked the Plan to pay for a pharmacogenetic PGxOne Plus panel. You say that this testing is supported in the records. The Plan denied your request. The Plan says this testing was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. A panel constitutes a single procedural service, so one code must be submitted for the panel. We find that CPT codes 81225, 81226, 81230, 81231, 81240, 81241, 81328, and 81408 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with one code. Based on this information, we decided that Medicare rules for coverage of a pharmacogenetic PGxOne Plus panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic PGxOne Plus panel (81225, 81226, 81230, 81231, 81240, 81241, 81328, 81408) provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213) to be rendered by the OON
provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are available providers within the network that
can render the requested services.
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 office
visits (99213) to be rendered by the OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6750, D6240, D2950) 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 service exceeds the maximum count allower per period.
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 the requested services once every five years. The same services were last received less than five years ago in 2018. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D6750, D6240, D2950) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted for a craniotomy and had a post-operative intracranial hemorrhage. The enrollee continues to have altered mental status and remains on the ventilator. The enrollee continues to receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The LTACH services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 these services are medically necessary. The Plan denied your request. The Plan says that 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation that you 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. You are undergoing a planned elective right total knee arthroplasty. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is listed under CPT code 27447 which is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that Zilretta has kept you pain free. The Plan denied your request. The Plan says the safety and efficacy has not been shown for repeat administration.
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 pre-approve Zilretta. Our physician reviewer found that you have osteoarthritis of the left knee. You have been receiving steroid injection every 3 months, but the pain relief was only 4-6 weeks. You had Zilretta on January 14, 2021, and had more than 4 months of pain relief. This request is to repeat Zilretta. The FDA prescribing information specifically states it is meant for a single lifetime use only. Repeat dosing has not been studied. Its safety and efficacy are unproven. Therefore, the request 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical procedure to correct drooping eyelids.You asked the Plan to pre-approvea surgical correction of eyelid droop. You say that drooping eyelids interfere with your vision.The Plan denied your request. The Plan says the requested procedure is not medically necessary because it is cosmetic.The Plan must follow Medicare rules. Medicare rules say that blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are reasonable and necessary when functional (to improve abnormal function) rather than cosmetic (to enhance appearance).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 surgical correction of eyelid droop. Our reviewer says that the requestedservices are not considered medically reasonable and necessary in this case. Our physician reviewer found that you have mild ptosis.The record indicates that Margin Reflex Distance measurements all exceed 2.0 mm.The elements of the coverage rule are notsatisfied. 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 surgical correction of eyelid droop have not been met.Therefore, we decided that the Plan does not have to pre-approvea surgical procedure to correct drooping eyelids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe total electric hospital bed (E0265).You asked the Plan to pre-approvethe hospital bed. You say that you have been trying to get this issue resolved for several months now. The enrollee is currently in a senior living facility and is sleeping on just a mattress.The Plan denied your request. The Plan says a total electric hospital bed is not covered.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may beappropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvethe total electric hospital bed (E0265).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRhopressa Solution (0.2%).You asked the Plan to pre-approveRhopressa Solution. You say that Rhopressa is medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.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-approveRhopressa Solution (0.2%).Benefits for Rhopressa Solutionmay be available under Medicare Part D.Contactthe 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 non-sterile gloves (A4927).
You asked the Plan to pre-approve non-sterile gloves. You say that the requested items are a necessity for the
enrollee's care. The Plan denied your request. The Plan says rules for durable medical equipment have not been
met.
The Plan must follow Medicare rules. The rules say that supplies such as gloves may be covered for patients
with ESRD.
The available documentation does not show that the enrollee has ESRD. Therefore, we decided that the Plan
does not have to pre-approve non-sterile gloves (A4927).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required
(D2950 x3) and two crowns (D2740 x2).
You asked the Plan to pre-approve the core buildups and crowns. You say that you would like these services to
be approved for coverage. The Plan denied your request. The Plan says core buildups are not a covered benefit.
The Plan also says that your crowns benefit has been exhausted for the 2021 plan year.
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, core buildup is not among those
covered under this benefit. The contract says that crown(s) are limited to one procedure per calendar year. The
record shows that you received approval for one crown for tooth #25 on March 22, 2021, and your crowns
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve three core
buildups, including any pins when required (D2950 x3) and two crowns (D2740 x2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says the Plan has in-network providers who can provide 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 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 physical therapy services to be provided by the requested out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (96374, 96375) provided on July 16, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford the copayment and would like the cost share to be waived. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. The EOC confirms that $90 is the required copayment for this service. 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 copayment for an emergency room visit (96374, 96375) provided on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on February 4, 2021.
You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that you were not aware that the services would not be covered. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers
available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethree crowns (D2740 x3) and four periodontal scalings and root planings (D4341 x4).You asked the Plan to pre-approvethe crowns and scalings and planings. You say that you cannot afford to pay for these services on your own.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the 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-approvethree crowns (D2740 x3) and four periodontal scalings and root planings (D4341 x4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.
You asked the Plan to pre-approve spinal fusion surgery. You say that your physician is willing to do the surgery knowing that you are a smoker and purchasing Chantix would be a financial burden. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you are a current smoker with no confirmation of smoking cessation which is a contraindication to surgery.
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 spinal fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found smoking is a contraindication to fusion and results in high fusion failure rates. You must stop smoking for 3 months.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the patient should continue receiving care in the acute care facility for maximum benefit of his condition.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.