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

We decided that the Plan does not have to pre-approve the removal of bone tissue (D7471).
You asked the Plan to pre-approve the removal of bone tissue. You say that this is necessary for your condition. The Plan denied your request. The Plan says this service is not covered by Medicare or the 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 the removal of bone tissue (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a saddle bag for a power wheelchair (K0108).
You asked the Plan to pre-approve the saddle bag. You say that this item is medically necessary. The Plan
denied your request. The Plan says this feature is not primarily medical in nature and is therefore non-covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a saddle bag for a power wheelchair (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0006).
You asked the Plan to pre-approve a manual wheelchair. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says you are currently not living at home where
this equipment would be provided.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided
that the Plan does not have to pre-approve a manual wheelchair (K0006).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral exam (D0120) and prophylaxis (D1110) to be provided by an out of network dentist.

You asked the Plan to pre-approve the dental services. You say that this is the only dentist that you can find that will provide sedation for you. You say that this is required in order to have dental work done. You also say that you are already comfortable with this provider which helps to ease your anxiety. The Plan denied your request. The Plan says services you receive out of network 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 services to be provided out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an oral exam (D0120) and prophylaxis (D1110) to be provided by an out of network dentist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.
You asked the Plan to pre-approve Praluent. The Plan denied your request. The Plan says the drug is covered by the pharmacy benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Praluent.
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the epigastric hernia repair (49572) provided on April 16, 2021.
You asked the Plan to pay for the epigastric hernia repair (49572). The Plan denied your request. The Plan says CPT code 49572 is considered inclusive to 49650.
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 49572 is repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated. We asked our coder 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 epigastric hernia repair (49572). Our reviewer says that this does not meet criteria for billing or reimbursement consideration. Our reviewer found that the medical records submitted do not include sufficient documentation to validate that CPT code 49572 was performed at an incision site different than the incision site of CPT code 49650. Therefore, 49572 is not eligible for reimbursement consideration as it would be incidental to 49650.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the epigastric hernia repair (49572) have not been met. Therefore, we decided that the Plan does not have to pay for the epigastric hernia repair (49572) provided on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services received on August 6, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT code 63030 is considered inclusive to 63056 and CPT code 63035 is conisdered inclusive to 63057.

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 asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not support a distinct procedural service. The operative report states that "this required extra degree of expertise, effort, and time" hence a modifier -59 is required for CPT 63056-63057, hence a modifier -59 would not be reported for increased services. In this case CPT 63030 would be inclusive to CPT 63056 as this procedure is performed at the same level, and more appropriate modifier should be reported. CPT 63035 is not supported by the documentation.

The operative report states "this required extra degree of expertise, effort and time, hence a modifier -59 is required for CPT code 63056 - 63057". Modifier -59 would not be reported for increased services. In this case CPT 63035 would be inclusive to CPT 63057 as this procedure is performed at the same level, and more appropriate modifier should be reported. 

We looked at this coder'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 pay for surgical services received on August 6, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Neulasta.
You asked the Plan to pre-approve Neulasta. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Fulphila, Udenyca, or Nyvepria before it will approve Neulasta.
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 Neulasta. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Neulasta. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Fulphila, Udenyca, or Nyvepria. The record does not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Neulasta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), pontic (D6245), two core buildups, including any pins when required (D2950 x2), and two retainer crowns (D6740 x2).  You asked the Plan to pre-approve the bone replacement graft, pontic, core buildups, and retainer crowns. The Plan denied your request. The Plan says the bone replacement graft and pontic are not covered benefits. The Plan also says that the core buildups and retainer crowns required additional clinical notes and x-rays from the provider that were not provided.  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 Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft (D4263) and pontic (D6245) are not among those covered under this benefit. The record shows that the Plan made multiple attempts to contact the provider to obtain additional clinical notes and x-rays, but each attempt to contact the provider by phone was unsuccessful. The medical necessity for the two core buildups, including any pins when required (D2950 x2) and two retainer crowns (D6740 x2) could not be confirmed without the additional notes and x-rays. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263), pontic (D6245), two core buildups, including any pins when required (D2950 x2), and two retainer crowns (D6740 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for
the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no
documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and
occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the
member has suffered from this condition for more than a year and has failed more than 6 months of
conservative approaches to treatment. The Plan denied your request. The Plan says there are not enough studies
on Vertiflex Superion to show it is safe and effective.
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 insertion of stabilization device
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found that 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 insertion of stabilization device (22869 and 22870) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869
and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).  

You asked the Plan to pre-approve the upper and lower partial dentures. You say that the first dentures were not done correctly and you need a new dentist to make a new set. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the upper and lower partial dentures once every five plan years.  

We looked at the file and Medicare rules. The Plan provided documentation showing that an upper and lower partial denture was previously covered by the Plan on February 9, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the upper and lower partial dentures has been exceeded. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gabapentin 300 mg capsule.  You asked the Plan to pre-approve Gabapentin. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gabapentin 300 mg capsule.   Benefits for Gabapentin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 7, 2022, forward.
You asked the Plan to pre-approve inpatient psychiatric care from February 7, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from February 7, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 7, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 7, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 7, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 7, 2022, forward.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an ExactVu prostate biopsy to be provided by the requested out-of-network facility.  

You asked the Plan to pre-approve an ExactVu prostate biopsy. You say that the member has a progressively rising prostate-specific antigen (PSA) and is in need of a prostate biopsy. You say that the member would benefit from a transperineal Exact VU prostate biopsy under intravenous (IV) sedation. The Plan denied your request. The Plan says that the Plan has in network facilities able to perform prostate biopsy.  

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an ExactVu prostate biopsy to be provided by the requested out-of-network provider.
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 enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records
provided the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require
physical therapy and occupational therapy services but based on the medical records provided the enrollee does
not require an intensive inpatient rehabilitation therapy program.
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 pre-approve two removals of torus mandibularis (D7473 x2) and an alveoloplasty not in conjunction with extractions (D7321).  You asked the Plan to pre-approve the removals of torus mandibularis and alveoloplasty. The Plan denied your request. The Plan says these services are not covered benefits.  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 two removals of torus mandibularis (D7473 x2) and an alveoloplasty not in conjunction with extractions (D7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar.
You asked the Plan to pre-approve Vraylar. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vraylar.
Benefits for Vraylar may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.