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

 We decided that the Plan does not have to pre-approve cervical spinal fusion for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of magnetic resonance imaging (MRI) or other neuroimaging that demonstrates pathological anatomy corresponding to symptoms  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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no correlation between the imaging studies and the physical findings. There is no documentation of instability, fracture, or tumor.  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 cervical spinal fusion for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).  You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested drug have not been met.  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 Euflexxa. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that records do not document the enrollee has failed at least three months of conservative therapy or has failed to respond to aspiration of the knee when effusion is present and intra-articular corticosteroid injection therapy when inflammation is a significant component of the patient's symptoms and intra-articular corticosteroids are not contraindicated.  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. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic exercise (97110) chiropractic manipulative treatment (98942) and electrical stimulation (G0283) provided on June 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that you and the provider were both told that you were covered and you would like to appeal the denial of payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Additionally, the services provided were for chronic neck pain and included physical therapy and electrical stimulation that are not covered under the Plan benefits. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for therapeutic exercise (97110) chiropractic manipulative treatment (98942) and electrical stimulation (G0283) provided on June 18, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70450) provided on May 27, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 70450 is a column II code to column I code 70496.  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 services (70450) provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the complete dentures (D5110 and D5120).  You asked the Plan to pre-approve the complete dentures. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee has exhausted the Plan's benefit for these services.  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. Specifically, documentation shows the member has already exhausted their Plan benefits for these services. Therefore, we decided that the Plan does not have to pre-approve the complete dentures (D5110 and D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on November 27, 2020 and the subsequent hospital care services coded 99232 provided November 28, 20220 to December 6, 2020 and the hospital discharge day management services coded 99239 provided on December 7, 2020.  You asked the Plan to pay for the initial hospital care services, the subsequent hospital care services, and the hospital discharge day management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99221, 99232, and 99239 is not supported in the medical record. Specifically, the documentation shows that a previous claim for the same dates of service was previously received by the Plan. There was no additional documentation submitted to support additional services were provided. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services, the subsequent hospital care services, and the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on November 27, 2020 and the subsequent hospital care services coded 99232 provided November 28, 20220 to December 6, 2020 and the hospital discharge day management services coded 99239 provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction (D7210), and placement of intra-socket biological dressing (D7922), provided on May 5, 2021.  You asked the Plan to pay for the extraction, and placement of intra-socket biological dressing. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered.  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. Specifically, the services obtained are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), and placement of intra-socket biological dressing (D7922), provided on May 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care could be received in another setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing or skilled therapy needs. There is no evidence of an acute decline in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care, such as long term care.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of daratumumab.  You asked the Plan to pre-approve daratumumab. You say that the enrollee was previously treated with Velcade but had an adverse reaction. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the requested use of daratumumab is not considered a standard of care.  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 daratumumab. Our reviewer says that the enrollee does not meet the criteria for the requested use of daratumumab. Our physician reviewer found daratumumab is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by major drug compendia or by clinical research appearing 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 daratumumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of daratumumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the custom fabricated abutments, abutment supported retainer and pontics.  You asked the Plan to pre-approve the custom fabricated abutments, abutment supported retainer and pontics. You say that the total for the surgery is $18,208 plus you are paying the extra coverage premiums. You say that you cannot believe you are being denied coverage and hope the decision will be reconsidered. The Plan denied your request. The Plan says your maximum benefit of $2,000 for the year have been reached.  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, you also have a maximum benefit of $2,000 for covered dental services per calendar year. The Plan paid $2,000 toward the dental services received during the year prior to the request for these services, which exhausted your benefits. Therefore, we decided that the Plan does not have to pre-approve the custom fabricated abutments, abutment supported retainer and pontics.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for a multigene panel provided to the enrollee on June 21, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says that all genes in the panel are not relevant to the personal and family history for the individual being tested.  The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have a personal history of breast cancer/invasive ductal carcinoma and you have a sister with ovarian cancer. The current guidelines recommend testing for high-penetrance cancer susceptibility genes, specifically BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53, in patients with breast cancer and a relative with ovarian cancer. Panel testing is a way to accomplish this.  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 testing have been met. Therefore, we decided that the Plan has to pay for a multigene panel provided to the enrollee on June 21, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93976) provided on April 18, 2021.

You asked the Plan to pay for a duplex scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable without a 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 93976 is a column II code to column I code 76856. 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 a duplex scan (93976) provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057).  You asked the Plan to pre-approve the custom fabricated abutment. You say that the abutment that needs to be replaced is 20 years old. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve a custom fabricated abutment (D6057).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have the services laboratory services provided to the enrollee on April 16, 2021.

You asked the Plan the services to pay for. You say that this was medically necessary. The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit.

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 the services to pay for. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the obtained laboratory test. The review has determined that the services at issue in this case were not 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 to pay for have not been met. Therefore, we decided that the Plan does not have the services laboratory services provided to the enrollee on April 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve physical therapy. You say that the enrollee has been to other PT facilities and has not had any success. The enrollee would like to see this OON provider. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.  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. The records provided for review do not show that the services at issue are urgent or emergent. 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 physical therapy (PT) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge.

You asked the Plan to pre-approve the bridge. You say that you were advised that you need a bridge, and it would cost $1,800. You also say that you cannot afford this and fear the tooth may be infected and could be damaging your heart. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve a dental bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the three surgical placements of implant bodies: endosteal implants (D6010 x3).

You asked the Plan to pre-approve the endosteal implants. You say that you say that there is not enough bone to hold the dentures because the bone was removed. You also say that you cannot chew food. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 pre-approve the three surgical placements of implant bodies: endosteal implants (D6010 x3).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.  You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no record of contact with the doctor after a recent six-week trial of treatment that failed to improve symptoms.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has only had a few chiropractic visits. Not enough conservative measures have been tried and failed for the back pain.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on December 21, 2020.  You asked the Plan to pay for the 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 indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 21, 2020.