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

 We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 9.  

You asked the Plan to pre-approve the extraction. You say that you need the extraction to be approved. The Plan denied your request. The Plan says the surgical extraction 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 the extraction 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 extraction. Our reviewer says that the surgical extraction for tooth # 9 is not medically necessary. Our physician reviewer found the provided x-ray is of poor quality in the anterior region, but it appears that there is sufficient tooth structure to allow for an extraction without any cutting procedure. The requested code, D7210, is limited to situations where bone must be cut to allow for the removal of the tooth. The reviewer found that the presentation of tooth # 9 on the supplied x-ray, it would not be anticipated that a cutting procedure would be required to remove it. Therefore, the reviewer found that a surgical extraction for tooth # 9 is not medically 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 extraction have not been met. Specifically, the file does not indicate that a cutting procedure would be required to remove tooth # 9. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 9.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa (J7323).  

You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc.  

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 Euflexxa. Our reviewer says that the requested drug, Euflexxa, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs, Orthovisc and Monovisc. The reviewer also found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria have not been met.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should require only short-term additional acute care services that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 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 dental bridge comprised of two retainer crowns (D6740) and one pontic (D6245) provided on April 26, 2021.  

You asked the Plan to pay for the dental bridge. You say that the Plan has not paid their half of the full bill as you expected. The Plan denied your request. The Plan says these services were covered and processed in accordance with your contract. You are responsible for 50% coinsurance on dental bridges, but you may pay more for services provided out-of-network. The provider in this case is out-of-network. 

 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 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 50% coinsurance for dental bridges. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the Plan pays, even for services listed as a $0 copayment.  T

he out-of-network provider billed the Plan a total of $3,264 for the two retainer crowns and pontic. The Plan's total maximum allowed cost for these services is $1,625. This is the amount that an in-network provider would accept as full payment for these services; however, out-of-network providers do not have this agreement with the Plan, and they are allowed to bill you for the difference between what they charge and what the Plan would pay for services ($3,264 - $1,625 = $1,639). In addition, you are responsible for 50% coinsurance on the Plan's allowed amount for these services ($1,625 x 50% = $812.50). You have been asked to pay $2,451.50 for the bridgework ($1,639 + $812.50 = $2,451.50). 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 pay any additional amount for the dental bridge comprised of two retainer crowns (D6740) and one pontic (D6245) provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare. 

 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 requested services. Our physician reviewer found that the requested interspinous process distraction devices remain experimental. More research is needed to show safety and efficacy. 

 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87481, 87798) rendered by the out-of-network (OON) provider on March 9, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization. 

 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 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 laboratory services (87481, 87798) rendered by the out-of-network (OON) provider on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter (K0800).  

You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  

The Plan follows Medicare rules. Medicare rules say that a power scooter is covered when all the criteria in the Medicare Rules section of this letter are 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 a power scooter. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not have a personal mobility deficit that impairs participation in mobility related activities of daily living.  

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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of excess skin.  

You asked the Plan to pre-approve removal of excess skin. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    

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 removal of excess skin. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our reviewer found you underwent bariatric surgery. You now have a pannus. The pannus is reported to reach below the pubic symphysis. The record does not indicate the presence of intertrigo recalcitrant to conservative treatments. Therefore, you do not meet criteria for the requested 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 removal of excess skin have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of excess skin.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  

You asked the Plan to pre-approve Prolia. You say that the enrollee has completed 5 years of treatment with Fosamax. You also say that it is contraindicated for the enrollee to take zoledronic acid because of this. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid.  

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 Prolia. Our reviewer says that the requested drug Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs, zoledronic acid. The reviewer found that there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. The reviewer also found that current guidelines do not designate five years of therapy with Fosamax as a contraindication to treatment with zoledronic acid. Therefore, the reviewer found that the request for Prolia is not medically necessary as the step therapy criteria has not been met.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), resin-based composite - three surfaces, anterior (D2332), and intraoral - periapical first radiographic image (D0220) provided August 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the limited oral exam, tooth extraction, filling and intraoral x-ray provided OON. You say that these services were medically necessary for tooth pain. The Plan denied your request. The Plan says these services were not determined to be due to an emergency and are not covered OON.  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 limited oral exam, tooth extraction, filling and intraoral x-ray provided OON when the services are medically necessary and reasonable.   We looked at the file and Medicare rules. In this case dental care was obtained from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam, tooth extraction, filling and intraoral x-ray provided OON have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), resin-based composite - three surfaces, anterior (D2332), and intraoral - periapical first radiographic image (D0220) provided August 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 13 chiropractic manipulative treatments (98940) radiologic 
examination, spine (72020) and outpatient office visit (99211) provided March 15, 2021 to April 29, 2021.

You asked the Plan to pay for the chiropractic services. You say that you want to appeal the denial of coverage 
of your chiropractor visits. You had checked with the Plan before you started going and was told they would be 
covered in full. The Plan denied your request. The Plan says these services are not covered under the Plan 
benefits.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 

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 the chiropractic services Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record includes a conclusory statement that there is cervical 
subluxation. The presence and level of the subluxation is not documented by physical examination or x-rays. 
The elements of the coverage criteria are not satisfied.

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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pay for 13 chiropractic manipulative treatments (98940) radiologic examination, spine (72020) 
and outpatient office visit (99211) provided March 15, 2021 to April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on August 12, 
2021.

You asked the Plan to pay for ultrasound 76705. You say that you are appealing with records to support this 
level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because code 76705 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable 
without an appropriate modifier.

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 
ultrasound 76705 is a column II code to column I code 93976. 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 an abdominal ultrasound (76705) provided on 
August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Visudyne.  You asked the Plan to pre-approve Visudyne. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Visudyne. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the requested drug is not being used for an enrollee with predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD). The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. In addition, the requested drug is subject to plan step therapy requirements which have not been satisfied. The elements of the coverage criteria are not satisfied.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Visudyne have not been met. Therefore, we decided that the Plan does not have to pre-approve Visudyne.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the outpatient mental health services provided on April 5, 2021.  You asked the Plan to pay for the outpatient mental health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has not provided any documentation or evidence in support of their denial of payment for the services rendered on April 5, 2021. Therefore, we decided that the Plan has to pay for the outpatient mental health services provided on April 5, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 26, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met.
Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 26, 2021.