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

We decided that the Plandoes not haveto pre-approvea custom abutment for tooth #7, #9, #11 and an abutment supported porcelain for tooth #9 and #11.You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no dental implants placed in the areas requested.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 dental services 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 dental services. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the integral portion of the treatment (placement of implant bodes) has not been done. Therefore, coverage for the implant abutments (D6057) and implant supported crowns (D6059) do not meet the criteria for coverage at this time.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 dental services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea custom abutment for tooth #7, #9, #11 and an abutment supported porcelain for tooth #9 and #11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 24, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 Planto pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483 and CPT 80307)
provided to the enrollee on July 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 the place of service on the CMS-1500 form line 24B must reflect the location of the patient when
the specimen was obtained.
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 the denied codes is:
HCPCS G0483:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia,
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g.,
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed
CPT 80307:
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
We find that CPT code 80307 and HCPCS G0483 are not supported in the medical record. Specifically, the
place of service on the CMS-1500 form must reflect the location of the patient when the specimen was 
obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of
place of service of a doctor's office (POS 11). 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 drug
testing services (HCPCS G0483 and CPT 80307) provided to the enrollee on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil tablets.
You asked the Plan to pre-approve Modafinil tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Modafinil tablets are not covered under the enrollee's Medicare Part B 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-approve Modafinil tablets.
Benefits for Modafinil tablets 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CT Scan of the thorax, abdomen and pelvis (71260 and 74177).You asked the Plan to pre-approvethe CT Scans. You say that youwould like reconsideration because the CT Scans are medically necessary.The Plan denied your request. The Plan says records show that the same test or one like it is on file and do not show the results or plans with this study.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 Scans. Our reviewer says that the CPT Scans are not medically necessary and reasonable. Our physician reviewer found the member had a PET-CT which included a CT of the chest, abdomen and pelvis. The only available clinic note does not document a need for re-imaging 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 Scans have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CT Scan of the thorax, abdomen and pelvis (71260 and 74177).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea nebulizer (E0570).You asked the Plan to pre-approvethe nebulizer. You say that you would like reconsideration because this supply is medically necessary.The Plan denied your request. The Plan says there are no current physical exam findings of any respiratory symptoms.The Plan follows Medicare rules. Medicare rules say that small volume nebulizer (A7003, A7004, A7005), and related compressor (E0570) are considered for coverage when it is reasonable and 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 nebulizer. Our reviewer says that there is no specific clinical rational for the requested device. The documentation indicates that there are no complaints of cough, shortness of breath, wheezing and there is a normal respiratory effort. Our physician reviewer found there are no current physical exam findings of any respiratory symptoms and have an albuterol inhaler to be used only as needed.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 nebulizer have not been met.Therefore, we decided that the Plan does not have to pre-approvea nebulizer (E0570).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically
necessary.
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 device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found this enrollee
presents with complaints of low back pain at 5/10 on the visual analog scale described as sharp with a slight
worsening of her left SI joint pain lately. The CT scan revealed multilevel spinal stenosis described as
moderate. Current evidence-based medical guidelines 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 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. This enrollee has at least moderate spinal stenosis at all lumbar
levels, and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis,
obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no
discussion of spinal instability on flexion/extension films. There is no documentation of the enrollee's height,
weight, or body mass index. There is no discussion indicating that a DEXA scan has demonstrated no
osteoporosis in this enrollee. Superion indirect lumbar decompression would not be considered the standard of
care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically
reasonable and necessary for the treatment of this enrollee's medical 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora crown and intraoral x-ray (D2740, D0220) provided September 1, 2020.You asked the Plan to pay forthe dental services. You say that these services should be covered.The Plan denied your request. The Plan says the benefit for these services was exhausted at the time the services were provided.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 record shows that the benefits for these services were exhausted previously on August 3, 2020.Therefore, we decided that the Plan does not have to pay fora crown and intraoral x-ray (D2740, D0220) provided September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generator for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysa review of the current medical literature indicates that this service is considered experimental and 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has refractory congestive heart failure. In this circumstance treatment with the Optimizer System (CPT0408T) device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). Therefore the efficacy of the Optimizer System (CPT 0408T) is still uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is
medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for
coverage of an inpatient skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 an
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that at the
time of admission to the skilled nursing facility the member was medically stable without an acute injury. The
member did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of
care. He was not expected to make measurable gains within a reasonable and predictable period of time or
require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not
require skilled therapy to establish a safe and effective maintenance program. The member did not have any
parental medication, complex wound care or nutrition given via a feeding tube. He was medically stable
without any acute exacerbations of chronic medical problems. His physical function was at or near his baseline
and he could have received further services at a lower level of care for custodial services. As a practical matter,
the member did not require any skilled services on an inpatient basis, at a skilled level of care at the time of the
admission to the skilled nursing facility.
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. Therefore, we decided that the Plan does not have
to pre-approve an inpatient skilled nursing facility (SNF) admission
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 10, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services you received were neither
emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
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 has network providers
available who can provide 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 the physician services provided on January 10,
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone replacement graft for ridge preservation -tooth #2.You asked the Plan to pre-approvethe dental services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medicallynecessary.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 ofMedicare 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-approvea bone replacement graft for ridge preservation -tooth #2
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (D5214).
You asked the Plan to pre-approve the dental services. You say that you lost your bottom dentures and need new ones. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit because you have already had this service performed on October 11, 2019, which is within the 60-month period. The health plan contract says D5214- one (1) per sixty (60) months. Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953)
and guided tissue regeneration (D4267) provided on September 9, 2020.
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that you do
not understand why this claim was denied. The Plan denied your request. The Plan says the bone replacement
graft is not a covered benefit. The Plan also says that there was no information provided that would suggest the
necessity of the guided tissue regeneration.
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 bone
replacement graft for ridge preservation (D7953) and guided tissue regeneration (D4267) provided on
September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider from August 27, 2019, to February 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
from August 27, 2019, to February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), any joint of upper extremity (73223).
You asked the Plan to pre-approve a MRI. You say that you need this service to see if there is a tear in your shoulder. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient has not had 6 weeks of conservative therapy. Therefore, the patient does not meet the criteria for an MRI. The request is considered not medically reasonable or necessary at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Specifically, the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), any joint of upper extremity (73223).