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

We decided that the Plan does not have to pre-approve dental 3-dimensional imaging (D0351), scaling (D4346), antimicrobial medication (D4381), and occlusal guard (D9944).

You asked the Plan to pre-approve dental services. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these dental services are not covered by the Plan's dental benefits.

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-approve dental 3-dimensional imaging (D0351), scaling (D4346), antimicrobial medication (D4381), and occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to pre-approve RFA and trigger point injections. You say that the initial medial branch block provided 80 to 90% pain relief for 4 months and the confirmatory procedure provided 60 to 70% pain relief which meets criteria, and the trigger point injections will take place at least 2 weeks after the facet joint procedure. The Plan says that the denial of authorization for these services is correct, because the enrollee does not meet the criteria for a repeat RFA and the information provided does not describe trigger points by palpation.We decided that the Plan has to pre-approve radiofrequency ablation.
The Plan follows Medicare rules. Medicare rules state that radiofrequency ablations may be covered when certain clinical criteria have been met. 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 RFA. Our reviewer says that the enrollee meets the Medicare criteria for repeat RFA. Our physician reviewer found the enrollee has tried therapy, transcutaneous electrical nerve stimulation (TENS), medications, and epidural steroid injections, and has prior RFA which documented at over 90% pain relief. This request for repeat RFA is medically reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve RFA.
We also decided that the Plan does not have to pre-approve trigger point injections.
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 trigger point injections. Our reviewer says that the enrollee does not meet the Medicare criteria for trigger point injections. Our physician reviewer found Medicare does not allow for multiple pain procedures on the same day. The trigger points are not well documented and therefore this request is deemed 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 trigger point injections have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA and trigger point injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair repair.
You asked the Plan to pre-approve the repair. You say that The Plan denied your request. The Plan says payment is made for only one wheelchair at a time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a separate wheelchair that has already been repaired. The file shows that this wheelchair is being used in the home. The file shows that this wheelchair serves the same purpose as the requested repaired wheelchair. Therefore, we decided that the Plan does not have to pre-approve a wheelchair repair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous interlaminar fusion device.
You asked the Plan to pre-approve a Vertiflex interspinous interlaminar fusion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Vertiflex interspinous interlaminar fusion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex interspinous interlaminar fusion device 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 a Vertiflex interspinous interlaminar fusion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous interlaminar fusion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional prophylaxis, cleaning (D1110).

You asked the Plan to pre-approve the dental services. You say that the enrollee would benefit from more frequent recalls every 3-4 months to help maintain health of the gums and calculus build up. It would also benefit the enrollee to come more frequently due to health condition with diabetes. The Plan denied your request. The Plan says this service exceeds the maximum benefit limitation.

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 contract allows only 2 cleanings every year. 

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-approve additional prophylaxis, cleaning (D1110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the CardioMEMs device in the setting of Congestive Heart Failure has 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulp vitality tests (D0460) and a tooth isolation
procedure (D3910).
You asked the Plan to pre-approve pulp vitality tests and a tooth isolation procedure. You say that you need
these services to get a root canal. 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-approve pulp
vitality tests (D0460) and a tooth isolation procedure (D3910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralightweight wheelchair and accessories to be provided by an out of network provider.
You asked the Plan to pre-approve an ultralightweight wheelchair and accessories. You say that the enrollee needs an ultralightweight wheelchair and accessories. The Plan denied your request. The Plan says an ultralightweight wheelchair and accessories are available in-network.
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 items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair and accessories to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 100 mg/ml injection.
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your
request. The Plan says a trial of Remicade or Inflectra, and Stelara must be documented before alternatives like
Ilumya can be considered.
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 Ilumya. Our reviewer says that Ilumya
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred
drugs or any reason why they would be unsafe or ineffective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya 100 mg/ml injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that you would like the complete denture to be approved. You say that you have a partial now. You say that the tooth that holds it in place needs to be removed. You also say that you need full dentures so you can be able to eat. The Plan denied your request. The Plan says complete upper denture is not listed as a covered service.

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 complete upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on October 13, 2020.
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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate POS code. We looked at the file and Medicare rules. The file shows that the claim for an office visit was billed with POS code 23 for an emergency room. This POS code is not appropriate for the setting in which the services were rendered. Therefore, we decided that the Plan does not have to pay for the office visit rendered on October 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy visits.

You asked the Plan to pre-approve 12 physical therapy visits. You say that continued physical therapy is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met with a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 12 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the available records, the patient appears to be making slow progress with therapy. Further formal therapy beyond the approved sessions does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate after the approved sessions.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9310).
You asked the Plan to pre-approve the services. You say that you are in pain from a bone sticking out of the jaw. The Plan denied your request. The Plan says this 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 pre-approve dental services (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts, surgical extractions, and extraction of erupted teeth.
You asked the Plan to pre-approve the services. You say that you cannot afford these services. The Plan denied your request. The Plan says this 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 pre-approve bone replacement grafts, surgical extractions, and extraction of erupted teeth.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99284) provided on August 6, 2020.
You asked the Plan to pay for an emergency room visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We looked at the file and Medicare rules. The service at issue was billed with a primary diagnosis of T50.3X5A, adverse effect of electrolytic, caloric and water-balance agents, initial encounter, without any additional diagnosis codes. Coding guidelines require the nature of the adverse effect to be coded first. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99284) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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. Our physician reviewer found that 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. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) (L0650) provided on August 24, 2020.
You asked the Plan to pay for a LSO. You say that the item is medically necessary. The Plan denied your request. The Plan says there was insufficient documentation submitted to establish the medical necessity of this item.
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 pay for LSO. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.
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 LSO have not been met. Specifically, there was insufficient documentation submitted to establish the medical necessity of this item. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) (L0650) provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panoramic x-ray (D0330).

You asked the Plan to pre-approve the dental service. You say that x-rays have always been covered at 100% under your dental plan. The Plan denied your request. The Plan says full mouth x-rays are covered once every 5 years. The Plan also says that the frequency limit for this service 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, the frequency limit of 1 full mouth x-ray every 5 years has been reached. The record shows that the Plan paid for a panoramic x-ray. Therefore, we decided that the Plan does not have to pre-approve a panoramic x-ray (D0330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network for hearing aids.
You asked the Plan to pre-approve the referral. You say that you don't want to go the plan providers. The Plan denied your request. The Plan says the services are available from an in-network provider.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network for hearing aids.