Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the femoral and obturator branches innervating the hip.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral hip osteoarthritis. He had intra-articular steroid injections in the past which provided him with only brief relief. He had left hip blocks on August 6, 2021 that provided 70 percent pain relief for two and a half days. The requested RFA is considered experimental/investigational in nature. The services are therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the femoral and obturator branches innervating the hip.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that the efficacy and safety of repeat administrations of Zilretta not been demonstrated.

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 Zilretta. Our reviewer says that the requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 72-year-old female with bilateral knee pain due to primary osteoarthritis of both knees. She received a corticosteroid injection in December 2020 and an intra-articular viscosupplemental injection (Synvisc) in February 2021. The enrollee received an injection with Zilretta in March 2021, which provided 6 months of pain relief. The provider is requesting a 2nd injection with Zilretta. Zilretta (triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. The product label, states: "Limitation of Use: The efficacy and safety of repeat administration of ZILRETTA have not been demonstrated." Based on the Label, it does not preclude use of the drug more than one time. In addition, based on the regulation 50.4.1 - Approved Use of Drug, Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. The documentation supports that Zilretta is medically reasonable and necessary for the patient and is safe and effective for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound you had on July 22, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that the Plan should pay something towards this service and only charge you 20% of the cost. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($110.61) is less than your copayment obligation, you are responsible for the full allowed 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 $125 copayment for diagnostic radiology services. 

You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the diagnostic radiology services 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 the retroperitoneal ultrasound you had on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a splint and supplies (29515 and Q4045)
provided on March 19, 2021.
You asked the Plan to pay for the application of a splint and supplies. You say that you would like
reconsideration because the supply code Q4045 is a separately reimbursable item and should not be included in
the reimbursement for the procedure. The Plan denied your request. The Plan says the documentation does not
show that separately identifiable procedures were performed.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the application of a splint and supplies have not been met. Specifically, the medical records
submitted are not for the billed date of service. We are unable to verify if the information submitted is
corroborated by the medical records or if Medicare coverage criteria have been met. Therefore, we decided that
the Plan does not have to pay for the application of a splint and supplies (29515 and Q4045) provided on
March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (procedure codes 99285 and 93010) provided to the enrollee.
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 services rendered to incarcerated members are not payable unless certain exceptions are met.
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 the denied codes is:
CPT 99285: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. CPT 93010: Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only We find that CPT codes 99285 and 93010 are not supported in the medical record. Specifically, these codes were rendered to an incarcerated patient. 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 hospital services (procedure codes 99285 and 93010) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy services provided May 20, 2021 to July 17, 2021.
You asked the Plan to pay for the massage therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. While the plan covers massage therapy provided as part of a physical therapy program, massage therapy provided in a retail setting is not a covered benefit. The provider at issue does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for massage therapy services provided May 20, 2021 to July 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.
You asked the Plan to pre-approve eyeglasses. You say that you lost your glasses and cannot see anything. The Plan denied your request. The Plan says there is no replacement benefit for lost glasses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that you received eyeglasses on October 1, 2021. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine eyeglasses. Therefore, we decided that the Plan does not have to pre-approve eyeglasses
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on June 8, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you switched providers and
were simply going to do your first cleaning in one and a half years. You say that you were under the impression
that a dental visit was free, and you cannot afford to pay $144 a year for insurance. The Plan denied your
request. The Plan says procedure code D0150 is only covered once every three plan years.
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
one comprehensive oral evaluation every three plan years. The Plan paid for the comprehensive oral evaluation
provided on January 29, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have
to pay for the comprehensive oral evaluation provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80048, 82728, 83615, 84145, 85379, 86140) provided October 21, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was billed with invalid modifiers.
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 codes 80048, 82728, 83615, 84145, 85379, & 86140 are not supported in the medical record. Specifically, the codes billed are not eligible to be billed with the "CS" modifier. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80048, 82728, 83615, 84145, 85379, 86140) provided October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided March 26, 2021.
You asked the Plan to pay for the lab services. You say that the procedure was medically necessary. The Plan
denied your request. The Plan says the billed code is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be
denied automatically as not medically necessary.
We looked at the file and Medicare rules. The code billed is non-covered under Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (81455) provided March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer bench and 2 grab bars (E0247 and E0241).
You asked the Plan to pre-approve transfer bench and 2 grab bars. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
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 transfer bench and 2 grab bars (E0247 and E0241).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021.
You asked the Plan to pay for the laboratory services. You say that the referring physician is a contracted provider in the Plan's network. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent or emergent.
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 record shows the referring provider was also 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. 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 the laboratory services provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $1,000 for the complete upper denture (D5110) and 
complete lower denture (D5120) provided on May 4, 2021. 
 
You asked the Plan to reimburse you $1,000 for the dental items. You say that you called the plan on 
November 18, 2020, and were assured that dentures would be covered in 2021. You say that now you are being 
told that dentures are not covered. You say that you were advised on a later call that there was no record of you 
being told that dentures would be covered. You also say that this should be covered. The Plan denied your 
request. The Plan says dentures are not covered dental items. 
 
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 dentures are not among those 
covered under this benefit. Additionally, the record shows that the plan representative advised that your 
coverage from 2020 would rollover to 2021. The record does not indicate that you inquired about your 
coverage in regard to dentures. The record also shows that you did not have coverage for dentures in 2020. 
Therefore, we decided that the Plan does not have to reimburse you $1,000 for the complete upper denture 
(D5110) and complete lower denture (D5120) provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 11, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were having a reaction to your insulin. 
You say that the paramedic helped get your blood sugar under control. You say that you did not want to go to 
the hospital because of the coronavirus. You also say that you took it upon yourself to take care of yourself at 
home. The Plan denied your request. The Plan says there was no transport provided. The Plan also says that 
since there was not transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
  
The ambulance company did not provide transport services on May 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiology visit and the pacemaker
testing you had on January 29, 2021.
You asked the Plan to waive the copayments for the cardiology visit and the pacemaker testing. You say that
you never had a charge for this service until you switched to this plan. You said that you cannot afford a $70
charge twice a year. The Plan denied your request. The Plan says you were charged these copayments
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 $50
copayment for diagnostic tests and a $20 copayment for visits with a specialist.
You have been asked to pay a $00 copayment for the cardiology visit and a $50 copayment for the pacemaker
testing. The pacemaker testing falls within the diagnostic tests benefit category and the cardiology visit is a
specialist visit. 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 copayments for the cardiology visit and the pacemaker
testing you had on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified periodontal procedure (D4999) and prefabricated resin crown (D2932) provided on August 16, 2021.
You asked the Plan to pay for the periodontal procedure and crown. You say that these services were necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified periodontal procedure (D4999) and prefabricated resin crown (D2932) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2740) for tooth #14 provided on August 24, 2021.

You asked the Plan to pay for the crown. You say that the crown was medically necessary, and you would like payment to be made. The Plan denied your request. The Plan says that the x-rays provided do not show that tooth #14 has a lot of tooth missing from a cavity or has a lot of damage from being broken.

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 crown when the services are medically necessary and reasonable. 

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 crown. Our reviewer says that the crown was medically reasonable and necessary. Our physician reviewer found you presented with what was described by the provider as a hole in the occlusal surface of the existing gold crown. The plan was to replace the crown with a new all ceramic crown to replace the defective gold crown. Our reviewer found that the provided x-rays do not show the hole in the occlusal surface of the crown, and this can only be seen clinically. It would be appropriate to replace a crown with such a perforation as it is difficult to properly repair the worn crown, with amalgam being the most common repair material. Our physician reviewer also found that it would be prudent to replace a crown that has developed a hole in the functional surface, and it would be medically necessary to replace #14 given the description of the situation in the treatment notes of the dental provider. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pay for the crown (D2740) for tooth #14 provided on August 24, 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.