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

We decided that the Plan does not have to pre-approve osseous surgery - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) for the lower left quadrant and upper left quadrant.

You asked the Plan to pre-approve the osseous surgeries. You say that you are in pain, especially when chewing. The Plan denied your request. The Plan says these services are not medically necessary for the procedure code.

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 osseous surgeries 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 the osseous surgeries. Our reviewer says that given the presentation of less than 3 teeth in the upper and lower left quadrants, and pocket depths not exceeding 3mm on the lower arch, the claim under code D4260 is not supported and does not meet criteria. Our physician reviewer found D4260 is a code reserved for quadrants that have four or more teeth that are involved and require the procedure. The supplied documentation shows that both the upper and lower quadrants have only three teeth each, and would therefore not be properly coded under D4260. Our reviewer found that it is also noted that pocket depths do not exceed 3mm on the lower arch, and would not require osseous surgery. Our physician reviewer also found that on the upper arch tooth #13 has one 5 mm pocket, and a request for osseous surgery following scaling and root planing should be made with a lesser code. 

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 the osseous surgeries have not been met. Therefore, we decided that the Plan does not have to pre-approve osseous surgery - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) for the lower left quadrant and upper left quadrant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve unlisted procedure, spine (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says the clinical value and effectiveness of the Intracept procedure in the setting of chronic lumbar pain have not been demonstrated in the peer reviewed literature.

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 unlisted procedure, spine (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). Our reviewer says that the procedure is not medically reasonable or necessary. Our physician reviewer found the patient has not had a non-steroidal anti-inflammatory drug trial or an epidural steroid trial. The requested procedure is considered experimental/investigational at this point. Therefore, the request is considered 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 unlisted procedure, spine (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 16, 2021, to April 18, 2021.

You asked the Plan to pay for the self-administered drugs. You say that going to the emergency room was reasonable due to the circumstances you were under. The Plan denied your request. The Plan says the self-administered drugs are not covered.

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 pay for the self-administered drugs provided from April 16, 2021, to April 18, 2021.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 26, 2021 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. The Plan denied your request. The Plan says services rendered by a provider who is not in network 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 26, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 12, 13, 14, 29, and 30, prefabricated abutments (D6056) for tooth #'s 12, 13, 14, 29, and 30, and implant supported porcelain/ceramic crowns (D6065) for tooth #'s 12, 13, 14, 29, and 30.

You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported porcelain/ceramic crowns. You say that your first dental implant does not fit or line up with another tooth.

You also say you cannot eat with it. The Plan denied your request. The Plan says implants are covered to replace only one tooth in the same part of your mouth. The Plan also says your dentist has asked to replace more than one tooth in this part of your mouth with an implant.

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 covered because tooth #'s 12, 13, and 14 are all in one quadrant, and tooth #'s 29 and 30 are in another quadrant, making more than one tooth being replaced in each arch. Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 12, 13, 14, 29, and 30, prefabricated abutments (D6056) for tooth #'s 12, 13, 14, 29, and 30, and implant supported porcelain/ceramic crowns (D6065) for tooth #'s 12, 13, 14, 29, and 30.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on January 24, 2021.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (64625).
You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that this service is considered medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 SI joint radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation of the lateral sacral branches is considered experimental/ investigation because of the very wide variation in efficacy documented in the literature. There are other evidence-based therapies available to treat the enrollee's condition. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (64625).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Varithena injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says conservative therapy must be tried for at least three months consistently and not intermittently as documented.

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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent venous duplex confirming the absence of truncal venous reflux. It was based on this that the enrollee likely was approved for and underwent lower extremity phlebectomy. The treating provider plans to perform sclerotherapy of residual veins. However, the procedure is coded for the Varithena sclerotherapy of two truncal veins. Furthermore, it is not clear that the enrollee is having lifestyle limiting symptoms, despite the regular use of compression stockings.

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Varithena injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lightweight transport chair purchased July 26, 2020, from provider not certified with Medicare.
You asked the Plan to pay for a lightweight transport chair. You say that you would like this claim reimbursed. The Plan denied your request. The Plan says this provider is not certified with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a lightweight transport chair purchased July 26, 2020, from provider not certified with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on March 18, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware that you needed to see an in-network dentist. The Plan denied your request. The Plan says the services are not included in your dental coverage when performed by an OON provider. The Plan also says that no authorization is on file, or any calls on file to verify the provider's network status or confirm your benefits before the services were rendered.

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 periodic oral evaluation and prophylaxis provided on March 18, 2021 by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 31, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services 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 have documented skilled nursing or therapy needs. 
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 provided 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on May 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained.
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 outpatient services provided on May 6, 2020 by an out of network (OON) provider.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) thorax (71250).

You asked the Plan to pre-approve the CT scan. You say that you are appealing the denial of the requested CT scan. The Plan denied your request. The Plan says the clinical information does not support the medical necessity criteria for the requested CT scan.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 68-year-old female who fell. X-rays revealed nondisplaced rib fractures and thickening along one of the fissures. There was no record of a follow-up after 3 weeks as planned. X-ray is the standard follow-up imaging method for evaluating thickening and was not shown to have been completed. Also, the requesting physician did not want to appeal according to the records. Therefore, this request for CT will be considered not medically necessary at this time. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) thorax (71250).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95907), needle electromyography (95885), and an unlisted diagnostic procedure (95999) provided on December 22, 2020.
You asked the Plan to pay for nerve conduction studies, needle electromyography, and an unlisted diagnostic procedure. You say that these services were coded correctly. The Plan denied your request. The Plan says these codes are 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. 
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 nerve conduction studies, needle electromyography, and an unlisted diagnostic procedure. Our reviewer says that these codes are not supported in the records.
Our physician reviewer found the medical records provided does not include documentation to validate that 95907, nerve conduction studies; 1-2 studies, was performed. The medical records provided indicates train of four testing was performed, which is not separately reimbursed when performed during intraoperative neurophysiological monitoring, therefore, this code is not eligible for billing or reimbursement. The medical records provided does not include documentation of 95885, needle electromyography, each extremity, with related para-spinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited, being performed on December 22, 2020. Pedicle screw stimulation is not a baseline nerve conduction study. 95999 is an unlisted procedure and no description was provided. In order to bill 95999, the operative note must include specific documentation that describes or indicates the procedure that is being billed under code 95999. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies, needle electromyography, and an unlisted diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95907), needle electromyography (95885), and an unlisted diagnostic procedure (95999) provided on December 22, 2020.