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

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT code 64636) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635), for the enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the enrollee has undergone two (2) sets of diagnostic MBBs. The S1 dorsal ramus is part of the innervation of the L5-S1 facet joint. However, the is that the request exceeds the number of levels allowed at one session. The practitioner must limit the injections to 2 levels as per the LCD. Only two levels are considered 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT code 64636) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from May 22, 2021, to June 8, 2021.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you disagree with the charges because you have no control over who saw you in the hospital. 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 30% coinsurance for out-of-network inpatient hospital care. You received inpatient hospital care from an out-of-network provider from May 22, 2021, to June 8, 2021. The total allowed amount is $992.56 and 30% of that is $297.73. You have been asked to pay the total coinsurance amount of $297.73 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 coinsurance for inpatient hospital care provided from May 22, 2021, to June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) to be performed by an out-of-network (OON) provider.
You asked the Plan to pre-approve a surgical tooth extraction performed by an OON provider. You say that you were approved to see another oral surgeon, but you had to wait too long for an appointment. You are in pain and need the service approved. The Plan denied your request. The Plan says you must see a participating dental network provider to receive dental 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. The Plan covers a tooth extraction when you see a participating dental network provider.
We looked at the file and Medicare rules. The requested provider in this case is not part of the Plan's dental network. Based on this information, we decided that the Plan's rules for coverage of a surgical tooth extraction performed by an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) to be performed by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that the enrollee may not be taking medication as prescribed. 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 Trulicity.
Benefits for Trulicity 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve the mattress. You say that please review the information provided regarding medical necessity for the air mattress E0277. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested powered pressure reducing mattress.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records show you have cerebral palsy but are ambulatory and participate in activities such as bowling. You do not have any pressure ulcers. The records do not show you have multiple stage 2 pressure ulcers or a large stage 3 or stage 4 pressure ulcer. You indicated to the durable medical equipment company that your last pressure ulcer was eight years ago. Based on this information, we decided that Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says SNF services are not medically necessary.
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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, daily skilled services are not required. As a practical matter, this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 15.
You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says porcelain crown 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 requested porcelain crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable toilet, ice pack, pillow, rollator, knee scooter and bootwalker
You asked the Plan to pre-approve the portable toilet, ice pack, pillow, rollator, knee scooter and bootwalker. You say that you would like reconsideration because you will require this equipment after surgery. The Plan denied your request. The Plan says the requested items are not Medicare covered benefits.
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose 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 portable toilet, ice pack, pillow, rollator, knee scooter and bootwalker. Our reviewer says that you do not meet criteria for the portable toilet as the documentation does not show that you are confined to a bed or room. You do not meet criteria for the bootwalker because the records do not show that you require stabilization for a medical reason, with the potential to benefit functionally. You also do not meet criteria for the rollator because the documentation does not show that you have a mobility limitation that significantly impairs your ability to participate in one of more mobility related activity of daily living in the home. Our physician reviewer found the requested ice pack and pillow are not considered primarily medical in nature and are therefore not covered. 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 portable toilet, ice pack, pillow, rollator, knee scooter and bootwalker have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable toilet, ice pack, pillow, rollator, knee scooter and bootwalker
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 radiofrequency ablation. 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 right knee pain with chrondromalacia. The enrollee is taking Lidocaine cream and Voltaren gel for pain. The enrollee is also taking BuTrans and Tylenol. The enrollee had diagnostic genicular nerve blocks and achieved 100% pain relief. The request is considered an experimental/ investigational procedure and therefore, it is deemed 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a maxillary partial denture provided by an OON provider. You say that you are in pain and need the dentures. The Plan denied your request. The Plan says services provided OON 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. The Plan covers a maxillary partial denture when obtained from a provider in the Plan's dental vendor network.
We looked at the file, and Medicare rules. The services in this case are requested to be performed by an OON provider. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture to be provided by an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another three to four weeks to continue weaning from ventilator and to transition from this acute illness, coronavirus. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-sterile gloves (A4927).

You asked the Plan to pre-approve the non-sterile gloves. You say that you need the nitrile exam gloves in order to take care of the enrollee's incontinence. The Plan denied your request. The Plan says this item is not covered under Medicare.

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 the non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray and does not have to waive the coinsurance for Medicare Part B drugs provided May 5, 2021.
You asked the Plan to waive the copayment for an X-ray and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. 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 $20 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Part B drugs administered by a provider. You received an X-ray on May 5, 2021. Therefore, you are responsible to pay the $20 copayment.
You received Medicare Part B drugs on May 5, 2021. The total allowed amount is $12.18 and 20% of that is $2.44. The total amount you owe is: $22.44. You have been asked to pay the total amount of $22.44 for an X-ray and Medicare Part B drugs. An X-ray falls within the outpatient hospital services benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 an X-ray and does not have to waive the coinsurance for Medicare Part B drugs provided May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable nebulizer (E0570).
You asked the Plan to pre-approve a portable nebulizer.. You say that the power goes off often where you live and you cannot use your current device without electricity. You cannot afford a battery operated nebulizer because you are on a fixed income. The Plan denied your request. The Plan says Medicare does not cover a nebulizer designed for specific portable use outside the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. We looked at the file, and Medicare rules. The records show that the Plan had approved nebulizer treatments on August 28, 2019. The documentation does not indicate that your current nebulizer is lost or irreparably damaged. A portable oxygen nebulizer for use outside the home is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a portable nebulizer. have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable nebulizer (E0570).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4), two resin-based composites (D2331 x2), and three surgical extractions (D7210 x3).
You asked the Plan to pre-approve the scalings and planings, resin-based composites, and surgical extractions. The Plan denied your request. The Plan says scaling and planing is not a covered benefit. The Plan also says that the resin-based composites and surgical extractions are limited to two in a 12-month period.
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, periodontal scaling and root planing (D4341) is not among those covered under this benefit. The contract says that fillings are limited to 2 restorations per 12-month period, and surgical extraction (D7210) is limited to 2 per year. The record shows that the Plan has approved two extractions and two fillings on August 18, 2021 and your restorations and surgical extractions benefits have been exhausted.
Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings
(D4341 x4), two resin-based composites (D2331 x2), and three surgical extractions (D7210 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow or fluid gf, 1 cc (CPT code Q4206) and the arthrocentesis (CPT code 20610), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has severe pain in the left and right knees. You state the enrollee has constant bilateral knee pain due to osteoarthritis, so they are having a hard time doing basic day to day activities. You state the enrollee has already tried nonsteroidal anti-inflammatory drugs (NSAIDs), and steroid injections. The Plan denied your request. The Plan says the services are not reasonable and necessary under Section 1862.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the results from this series of injections are not known. In addition, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for fluid flow or fluid gf, 1cc (Q4206) and arthrocentesis (20610) 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow or fluid gf, 1 cc (CPT code Q4206) and the arthrocentesis (CPT code 20610), for the enrollee.