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

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 3, 7, 8, 9, and 13 and retainer crowns (D6750) for tooth #'s 4, 5, 6, 10, 11, and 12.

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says the requested 11-unit fixed bridge is beyond the scope of the policy benefit coverage.

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 pontics and retainer crowns 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 pontics and retainer crowns. Our reviewer says that due to coverage limitations the Plan criteria have not been met. Our physician reviewer found given the Plan requirements for fixed bridgework, the number of missing teeth, multiple abutments, and missing posterior teeth, would preclude a finding of necessity for the requested procedures. Our reviewer also found that it is not clear from the provided records why the replacement would be necessary. 

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 pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 3, 7, 8, 9, and 13 and retainer crowns (D6750) for tooth #'s 4, 5, 6, 10, 11, and 12.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
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 physician reviewer found that in this case, the enrollee was admitted for shortness of breath and developed hypoxic respiratory failure with metabolic encephalopathy. She continues to receive acute care services that have not been denied. The record does not indicate that she currently requires services which they are not receiving that would be available at the LTACH. Therefore, the requested services are not 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on December 3, 2020.
You asked the Plan to pay for the dental services. You say that you had to change dentists. You say that you were dissatisfied with your last dentist. You also say that the plan only paid for the removal of your last 3 natural teeth. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan says that 1 panoramic x-ray or complete series x-ray is covered every 5 years. The Plan also says that the frequency limits have been exceeded.
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on June 23, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 15, 2020, to May 16,
2020, by an OON provider.

You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan
denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on May 15, 2020, to
May 16, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
October 27, 2020, through October 28, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the documentation provided did not establish medical necessity for the inpatient 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented on October 26, 2020 for a CT angiogram of the lower extremities and underwent PCI left SFA. Post procedure had tachycardia and hypotension. Labs revealed K+3.5 and WBC increased to 15; CXR with RLL opacity. The enrollee was treated with IV fluids and IV antibiotics (Rocephin/Azithromycin) and admitted. On October 28, 2020 his condition stabilized and improved, and he was discharged home with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 27, 2020, through October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 6, 2020.
You asked the Plan to pay for the office visit. You say that you submitted the medical records for reconsideration of payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 office visit provided by an out-of-network provider on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on November 17, 2020 by an out of network provider.
You asked the Plan to pay for Radiologic examination, chest; 2 views (71046), Transportation of portable x-ray equipment (R0070), Set-up portable x-ray equipment (Q0092), and Electrocardiogram (93000). You say that you had no time to obtain authorization. The Plan denied your request. The Plan says prior authorization was denied but not appealed.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the radiology services provided on November 17, 2020 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from September 13, 2017, through September 30, 2017.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the claim was submitted beyond the 180-day claim submission timeline.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the SNF services was not filed until December 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for SNF services provided from September 13, 2017, through
September 30, 2017.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on October 7, 2019.
You asked the Plan to pay for the psychotherapy. You say that previous dates of service were processed and paid without a referral. You say that the claim should be reprocessed accordingly. The Plan denied your request. The Plan says prior authorization was required but 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 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 psychotherapy provided by an out-of-network provider on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and radiologic exam provided on July 24, 2020 by an out of network provider.
You asked the Plan to pay for the office visit (99213) and radiologic exam (73502). You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request prior authorization or verify the enrollee's eligibility.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the office visit and radiologic exam provided on July 24, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on December 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says NCCI edits apply to these services.
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 71045 is "Radiologic examination, chest." We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted contains a radiology report for a chest x-ray with two claims: 820510050005009 CPT 36556, and 82021005005250 for CPT 71045. The chest radiologic examination is integral to the procedure, and should not be reported separately, without the correct modifier and documentation to support a separate procedure. The documentation did not include documentation to support billing CPT 71045 in addition to the primary service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on April 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on April 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing on the upper left quadrant- 4 or more teeth (D4341).

You asked the Plan to pre-approve periodontal scaling and root planing on the upper left quadrant- 4 or more teeth. You say that you would like the Plan to cover this service. The Plan denied your request. The Plan says the service at issue is not medically necessary.

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 periodontal scaling and root planing - 4 or more teeth 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 periodontal scaling and root planing - 4 or more teeth. Our reviewer says that the criteria for this service has not been met. Our physician reviewer found this code is reserved for those instances where is there is diagnosed periodontal disease in 4 or more teeth in a quadrant. In this case, where there are less than 4 involved teeth in a quadrant, and in this case less than a total of 4 teeth in the quadrant, the code would not be appropriately used. There is a lesser code that can be used for instances where there are less than 4 teeth to be treated that would be more appropriate.

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 periodontal scaling and root planing - 4 or more teeth have not been met. Specifically, the criteria for the service at issue has not been met because there are less than 4 teeth in the quadrant. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing on the upper left quadrant- 4 or more teeth (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation does not show that the home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power-operated vehicle.
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the physician medical progress reports do not support that you have a personal mobility deficit that impairs participation in MRADLs in the home. Physician office notes of February 5, 2021 and March 12, 2021 show that you have a normal gait and station, normal tone and motor strength. The 3/2/21 review of systems notes no fatigue or weakness. The documentation is not clear that the mobility deficit is unable to be helped by the use of a walker, cane, or manual wheelchair. There is no evidence that you could safely use the wheelchair in the home. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography and professional component provided on September 23, 2020.
You asked the Plan to pay for the screening mammography and professional component. You say that your doctor told you to have another mammogram. The Plan denied your request. The Plan says you had a screening mammography on February 14, 2020 therefore this service is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Your contract with the Plan only covers one screening mammography every 12 months. Therefore, we decided that the Plan does not have to pay for the screening mammography and professional component provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the clinical value for the requested procedure has not been demonstrated in the peer-reviewed medical 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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are an 84-year-old female being treated for spinal stenosis, lumbar region, with neurogenic claudication. You may benefit from the Vertiflex device; however, current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Vertiflex Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 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 Vertiflex surgery 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no previous step therapy with the plan-approved drugs.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found you have not tried and failed the plan's preferred step one agents. The records do not indicate any contraindication to the plan's preferred drugs. There is no evidence that the preferred drugs would have an adverse effect. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane injections.