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 28, 29, 30, and 31, retainer crowns (D6750) for tooth #'s 27 and 32, and prefabricated post and cores in addition to crowns (D2954) for tooth #'s 27 and 32.
You asked the Plan to pre-approve the pontics, retainer crowns and prefabricated post and cores. The Plan denied your request. The Plan says pontics (D6240) for tooth #'s 30 and 31 are not valid for these teeth (molar teeth). The Plan also says that these services do not meet the guidelines for coverage due to the retainer teeth having an unfavorable long-term prognosis.
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, retainer crowns and prefabricated post and cores 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, retainer crowns and prefabricated post and cores. Our reviewer says that there is no medical necessity for the requested bridge. Our physician reviewer found tooth #27 is endodontically treated and is missing almost all of the coronal structure. Our reviewer found that tooth #32 is also endodontically treated, and suffers from periodontal disease with over 40% bone loss seen on x-ray. In general, a bridge must have abutments that are sufficient to support the missing teeth it is replacing. An endodontically treated tooth is a poor abutment as the risk of fracture is much greater. A tooth that requires a post support is at even greater risk of fracture as forces are directed along the post space with its thinner walls. Bone support should be at least 50%, and this would be relative to the number of missing teeth to be replaced. The Plan limits the use of porcelains on metal crowns on molar teeth as requested. In this instance the span (6 units) has four pontics and would be supported by two compromised abutments, making the bridge unreasonable to fabricate. Our physician reviewer also found that the span is too long with inadequate support and would have a poor prognosis. 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, retainer crowns and prefabricated post and cores have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 28, 29, 30, and 31, retainer crowns (D6750) for tooth #'s 27 and 32, and prefabricated post and cores in addition to crowns (D2954) for tooth #'s 27 and 32.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on September 30, 2021.
You asked the Plan to pay for the therapeutic activities. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the
qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner,
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on August 20, 
2020. 
 
You asked the Plan to pay for the laboratory 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 are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81479) provided on 
August 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiology stress test provided on March 30, 2021.
You asked the Plan to waive the copayment for a nuclear medicine cardiology stress test. You say that you were overcharged with a facility fee on your copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $495 copayment for in-network nuclear medicine services at an outpatient hospital. You have been asked to pay a $495 copayment for a cardiology stress test. You have not been charged a facility fee. A cardiology stress test falls within the Outpatient Hospital Services benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a cardiology stress test provided on March 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the drug combination Keytruda, Pemetrexed and Carboplatin with Dexamethasone.
You asked the Plan to pre-approve the requested drug regimen. You say that this drug regimen is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drug regimen. Our reviewer says that the requested drug combination is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a diagnosis of stage IV lung adenocarcinoma that is Estimated Glomerular Filtration Rate (EGFR) exon 19 positive, programmed death-ligand 1 (PD-L1) 10%, no other actionable mutation. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition.
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 requested drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve the drug combination Keytruda, Pemetrexed and Carboplatin with Dexamethasone.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for OneTouch Ultra test strips.
You asked the Plan to pre-approve a tier exception for OneTouch Ultra test strips. You say that the exception is needed. The Plan denied your request. The Plan says the items do not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for OneTouch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for OneTouch Ultra test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 22, 2021.
You asked the Plan to pay for the laboratory 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 are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion interspinous 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 Superion interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found 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 Superion interspinous 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 Superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on July 16, 2021.
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 a modifier was not billed on the claim to represent the services as separate/distinct.
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, we have confirmed that code 71045
is a column II code to column I code 70146. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for radiology services provided to the enrollee on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2021. 
 
You asked the Plan to pay for the laboratory 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 are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
 We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trastuzumab.
You asked the Plan to pre-approve Trastuzumab. You say that this drug is medically necessary. The Plan
denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Trastuzumab. Our reviewer says that
the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has
been diagnosed with platinum resistant ovarian cancer and is BRCA+ and HRD+. In this case, Trastuzumab is
not FDA-approved for the enrollee's diagnosis. In addition, the requested use of Trastuzumab is not supported
by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical
journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trastuzumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Trastuzumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Moderate sedation services (99156) provided on March 
25, 2021. 
 
You asked the Plan to pay for code 99156. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 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, we have confirmed that code 99156 
is a column II code to column I code 27265. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Moderate sedation services (99156) provided on March 25, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81381 and 81381-59) provided on 
September 9, 2021. 
 
You asked the Plan to pay for the laboratory 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 are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results.  
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81381 and 81381-59) provided on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2021. 
 
You asked the Plan to pay for the laboratory 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 are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 24, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you were told that it was an emergency, and it is being billed as a non-emergency. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 for a one-way ambulance trip, for both in and out of network. Regardless of whether the situation was an emergency or non-emergency the copayment is the same. You have been asked to pay a $290 copayment for ambulance services. Ambulance services falls within the Ambulance
Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on April 28, 2021.
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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, we have confirmed that code 83789 is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 9, 2021.
You asked the Plan to pay for the laboratory 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 are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus strips. You say that the items are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Accu-Chek Aviva Plus strips have not been met. Specifically, medical records were not provided. 
Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan 
does not have to pre-approve Accu-Chek Aviva Plus strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 consultation to be provided by an out-of-network (OON) provider.