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

We decided that the Plan does not have to pay for an osseous dental surgery (D4260, D4261) provided on July 
12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an osseous dental surgery. You say that you visited the provider and had your top 
gums cut to save your teeth because they were getting loose. You also say you called the Plan prior to your 
appointment and the Plan indicated the provider was OON. The Plan denied your request. The Plan says the 
services provided are not covered by your Plan and the provider was 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. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of osseous dental surgery have not been met. Specifically, the services were rendered by an OON 
provider. Therefore, we decided that the Plan does not have to pay for an osseous dental surgery (D4260, 
D4261) provided on July 12, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have a prosthetic hip joint and cannot bend down. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally-invasive left sacroiliac joint fusion for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this request for the treatment of mechanical low back pain is considered 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 at this point, the enrollee needs a second confirmatory block before the sacroiliac joint fusion can be
deemed medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve minimally-invasive left sacroiliac joint fusion for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a licensed practical nurse (LPN) (G0300) and hospice or home health care (Q5001) provided from March 7, 2021, to March 31, 2021
You asked the Plan to pay for the direct skilled nursing services of a LPN and hospice or home health care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 2, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of a licensed practical nurse (LPN) (G0300) and hospice or home health care (Q5001) provided from March 7, 2021, to March 31, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prometheus Anser IFX testing and thiopurine metabolite testing.
You asked the Plan to pre-approve Prometheus Anser IFX testing and thiopurine metabolite testing. You say that the requested Anser IFX testing and thiopurine metabolite testing are medically necessary. The Plan denied your request. The Plan says the requested Anser IFX testing is not medically necessary. Furthermore, the thiopurine metabolite testing can be provided through an in-network laboratory.
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 Prometheus Anser IFX testing. Our reviewer says that the requested Anser IFX testing is not medically necessary. Our physician reviewer found no recent physical examination, abdominal imaging, nor current inflammatory markers were provided to support objective concern that the enrollee is losing therapeutic response to current therapy. As such, proposed Anser IFX testing for the enrollee does not meet the spirit of specialty-society guidance relative to the routine therapeutic drug monitoring service under review. Medicare rules also 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 thiopurine metabolite testing at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/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 Prometheus Anser IFX testing and thiopurine metabolite testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Prometheus Anser IFX testing and thiopurine metabolite testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transport (A0427) and ground 
mileage (A0425) provided on January 13, 2020. 
 
You asked the Plan to pay for the transportation services. You say that it is not your fault that the claim was 
submitted so late. You also say that the services should be covered. The Plan denied your request. The Plan 
says the claim was not filed within the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the transportation services was not filed until August 2, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency ambulance transport (A0427) and ground mileage 
(A0425) provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on February 9, 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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
date of service at issue. Therefore, we decided that the Plan does not have to pay for the services rendered on 
February 9, 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 an intensive, complex, multidisciplinary approach to daily therapy. While you may benefit from physical therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility or in home with therapies and 24-hour caregiver assistance. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the anal endoscopy procedure you had in your colorectal surgeon's office on July 7, 2021.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that this service was a post-operative exam, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $15 copayment for medical care or surgery services furnished in a physician's office. 

You have been asked to pay a $15 copayment for the endoscopy procedure. Records show that you had hemorrhoid surgery on May 7, 2021. Two months later, you returned to the colorectal surgeon's office for the anal endoscopy. The billing records show that this related procedure was 'staged', meaning that your surgeon planned to do this related procedure at a separate time. Medicare rules state that when you have a surgery, certain services related to the surgery are packaged into the payment for the surgery itself, and separate cost sharing would not apply. This is called the global surgical package. However, related or 'staged' procedures are not part of the global surgical package and are separately payable. That is why the endoscopy procedure falls within the medical care or surgery services furnished in a physician's office benefit category for which separate cost sharing applies. 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 the anal endoscopy procedure you had in your colorectal surgeon's office on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zinplava.

You asked the Plan to pre-approve Zinplava. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated for the enrollee.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 Zinplava. Our reviewer says that the requested use of Zinplava is not supported. Our physician reviewer found the submitted medical records do not document high risk factors for recurrence of Clostridioides difficile infection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zinplava have not been met. Therefore, we decided that the Plan does not have to pre-approve Zinplava.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on June 7, 2021.
You asked the Plan to pay for the dental service. You say that this service is part of the process for getting crowns on 2 of your teeth. You also say that this service was necessary. The Plan denied your request. The Plan says clinical crown lengthening is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the clinical crown lengthening is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection 
provided on May 26, 2021. You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection. You say that you are 
submitting medical records to support this service and believe the denial is incorrect. The Plan denied your 
request. The Plan says an appropriate modifier was not billed with this code edit. 
 
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 96374 
has a bundled relationship with code 96360 and cannot be paid as billed. This code cannot be paid as a separate 
line item. 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 therapeutic, prophylactic, or diagnostic injection provided on May 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on February 25, 2020. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says you must select a 
device from a covered list available through our participating hearing aid supplier. Hearing aids may require 
prior authorization from our hearing supplier. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only available through the Plan's participating hearing aid supplier. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided through the 
Plan's participating hearing aid supplier. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom knee orthosis (L1846).
You asked the Plan to pre-approve a custom knee orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 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 custom knee orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding abnormalities that would indicate a need for the requested custom brace over a guideline-recommended prefabricated brace. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
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 custom knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom knee orthosis (L1846).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) (CPT code 23472 X 2), for the enrollee.
You asked the Plan to pre-approve the service. You say that surgical intervention is justified without further nonoperative treatment. You state both radiographs and computed tomography reveals the humeral head to be subluxated 76% posteriorly in relation to the normal reduced position of the humeral head on glenoid. You state the extent of posterior subluxation of the shoulder joint and the degree of shoulder erosion cannot be addressed adequately with nonoperative means of treatment. You state delay of this surgery will only serve to compromise the enrollee's outcome and longevity of implants if the erosion were to progress beyond the point their shoulder could be perfectly corrected. The Plan denied your request. The Plan says the service 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The noted published, large-scale, long-term peer-reviewed literature does not support moving forward with the requested total shoulder arthroplasty without a trial and failure of conservative treatments. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left arthroplasty, glenohumeral joint, total shoulder (glenoid and proximal humeral replacement) (CPT code 23472) 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) (CPT code 23472 X 2), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of 
your health problem. 
 
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 surgery. 
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 surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 
22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periapical first radiographic image (D0220) and a 
periapical additional radiographic image (D0230) provided on June 29, 2021. 
 
You asked the Plan to pay for a periapical first radiographic image and a periapical additional radiographic 
image. You say that you tripped and fell, striking your mouth on the floor. You also say further visits may be 
needed as there is numbness in your lip and shifting of your teeth. The Plan denied your request. The Plan says 
you were not covered for the services rendered. 
 
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. The records show that you did not enroll in the optional supplemental 
benefit. Therefore, we decided that the Plan does not have to pay for a periapical first radiographic image 
(D0220) and a periapical additional radiographic image (D0230) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial denture (D5213) provided on May 25, 2021.
You asked the Plan to pay for a partial denture. You say that it is essential to have dentures in order to survive. You also say that you are asking if the Plan can help pay a percentage of this bill. The Plan denied your request. The Plan says there is no coverage for maxillary partial dentures.
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 a partial denture (D5213) provided on May 25, 2021.