Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says this procedure is considered experimental/investigational for the
enrollee's condition.

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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft in the nasal, maxillary, or malar areas (21210), a prefabricated abutment (D6056), and a single crown restoration supported by an abutment (D6058).
You asked the Plan to pre-approve a bone graft, a prefabricated abutment, and a single crown restoration. You say that you need teeth to be removed for appropriate procedures to fix jaw due to TMJ syndrome and rheumatoid arthritis. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 a bone graft, a prefabricated abutment,
and a single crown restoration. Our reviewer says that the requested services have not been documented to be medically reasonable and necessary in this case. Our physician reviewer found that bone grafts, implants and teeth extractions were indicated but there was no documentation of your dental condition. Dental radiographs were not included in the documentation. The Plan does cover basic dental procedures and other surgical and restorative procedures; however, due to the lack of documentation the criteria for coverage for dental services have not been met. What is required are specific procedure codes, radiographs and dental records. 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 bone graft, a prefabricated abutment, and a single crown restoration have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone graft in the nasal, maxillary, or malar areas (21210), a prefabricated abutment (D6056), and a single crown restoration supported by an abutment (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 24, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the provider is in-network and the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on September 24, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for DXA bone density screening (77080) provided on June 23,
2021.

You asked the Plan to pay for the DXA bone density screening. You say that you would like reconsideration
because the member is the correct age and the diagnosis billed is appropriate. The Plan denied your request.
The Plan says the claim was not billed with a diagnosis representing a reason for this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 77080 is not supported in the record. Specifically, this claim was not reported with an
appropriate diagnosis code for the service billed. The diagnosis code reported on the claim does not indicate the
reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Based
on this information, we decided that Medicare rules for coverage of the DXA bone density screening have not
been met. Therefore, we decided that the Plan does not have to pay for DXA bone density screening (77080)
provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint fusion.

You asked the Plan to pre-approve minimally invasive sacroiliac joint fusion. You say that you feel these
services are medically necessary. 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 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 minimally invasive sacroiliac joint
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has symptoms of bilateral buttock pain and
pain shooting down the right leg. There is L5-S1 disc degeneration and leg pain with radiculopathy. There is no
clear medical evidence that the sacroiliac joint is the pain generator. Therefore, the enrollee does 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 minimally invasive sacroiliac joint fusion have not been met. Therefore, we
decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant maintenance procedure (D6080) provided on June 10, 2021.

You asked the Plan to pay for implant maintenance. You say that this procedure should be covered just like any other cleaning. The Plan denied your request. The Plan says this service is not covered by your dental 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 pay for the implant maintenance procedure (D6080) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on February 8, 2021, and
February 9, 2021.

You asked the Plan to pay for subsequent hospital care (99232) provided on February 8, 2021, and February 9,
2021. You say that the Plan should pay this claim. The Plan denied your request. The Plan says medical records
for dates of service February 8 and February 9 were requested but not received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99232 is Subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components.

We find that CPT code 99232 is not supported in the medical record. Specifically, there are no medical records
for dates February 8, 2021, and February 9, 2021, therefore the services cannot be verified. Based on this
information, we decided that Medicare rules for coverage of subsequent hospital care (99232) provided on
February 8, 2021, and February 9, 2021, have not been met. Therefore, we decided that the Plan does not have
to pay for subsequent hospital care provided on February 8, 2021, and February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the core buildup, including any pins when required (D2950) provided on February 22, 2021.
You asked the Plan to pay more for the core buildup. You say that you feel that the limit your Plan pays for dental services is not enough. The Plan denied your request. The Plan says you have met your annual maximum 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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on while processing this claim for the February 22, 2021 date of service and your annual
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the
core buildup, including any pins when required (D2950) provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on June 15, 2021.
You asked the Plan to pay for the gingival irrigations. The Plan denied your request. The Plan says your calendar year maximum has been met.
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 Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the June 15, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 5, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MI Tumor Seek testing rendered on March 4, 2021.
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 services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when
specific criteria 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has metastatic
adenocarcinoma of the breast. The submitted documentation contains results of genetic testing. There are no
clinical records. The documentation is insufficient to support that the enrollee has decided to seek further
cancer treatment. The criteria for coverage are not met and the testing was therefore not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the MI Tumor Seek testing rendered on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 28, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that since the original provider was not able to provide the root canal and referred you to another provider, this service should be covered. The Plan denied your request. The Plan says benefits for this service are limited to one time per calendar year.
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, emergency diagnostic exam is limited to 1 per year. The record shows that you received a problem focused limited oral evaluation (D0140) on March
16, 2021 and your emergency diagnostic exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 8, 2021.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you were not aware that dentures were not covered under your plan. You also say that you feel these dentures should be covered. The Plan denied your request. The Plan says these services are not covered under the terms of your policy.
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 complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 21, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that a piece of equipment was left in your body and you were consulting with a physician about removing it and this should be considered as a post-operative follow-up. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment per visit to a specialist visits. 

The medical records show that you had a specialist visit on April 21, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. 

You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on April 21, 2021.
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 does not meet criteria.
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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on May 20, 2021 by an OON provider.
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you had a bad infection in your gum. You also say that if the infection was not taken care of you might have lost your tooth. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says that this service is not covered by your dental plan.
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 localized delivery of antimicrobial agents (D4381) provided on May 20, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 ten (10) additional PT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have normal gait, normal and pain free ankle and feet range of motion and full strength in the bilateral lower extremities per the podiatrist exam documentation. The podiatrist indicates iontophoresis will help with strengthening and stretching exercises, but you have full strength and full range of motion. You can participate in stretches and strengthening independently without ongoing formal therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.