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

 We decided that the Plan does not have to pay for drug testing provided on July 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for drug test. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with the Plan.  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. 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 drug testing provided on July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal injection to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the spinal injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.

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. 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 the spinal injection to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. You say that in-network options are too far for you to drive. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan, you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.  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 physical therapy services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingles vaccine received on August 6, 2021.  You asked the Plan to pay for the Shingles vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine received on August 6, 2021.   Benefits for the Shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6754) for teeth # 27, 28 and 31, and pontics (D6245) for teeth # 29 and 30.

You asked the Plan to pre-approve the dental services. You say that a new bridge is medically necessary to prevent further decay chipping, cracking and breaking of bridge and teeth that may necessitate further extractions and overall decline in chewing and eating functions. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services either.

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 retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6754) for teeth # 27, 28 and 31, and pontics (D6245) for teeth # 29 and 30.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 0037U provided on June 10, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 0037U provided on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

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 in this case, the complexity of your nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 74170 provided on September 21, 2020.

You asked the Plan to pay for the CT. 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. 

In this case, the CPT Code Manual definition of code 74170 is computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections.

We find that CPT code 74170 is not supported in the medical record. Specifically, the documentation shows that this code was already approved and paid by the Plan. There is no additional documentation supporting an additional study. Based on this information, we decided that Medicare rules for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) coded 74170 provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup, including any pins (D2950) and a topical application of fluoride varnish (D1206).  You asked the Plan to pre-approve a core build up and a topical application of fluoride varnish. You say that the dental services are a medical necessity, and you are asking for reconsideration. The Plan denied your request. The Plan says the requested services are not covered 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 core buildup, including any pins (D2950) and a topical application of fluoride varnish (D1206).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion.  

You asked the Plan to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion. 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 minimally invasive percutaneous sacroiliac (SI) fusion. 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 chronic right sided SI joint pain, sacroiliitis. There is no documentation of adequate physical therapy for back pain. There is no SI joint instability, fracture, or lesion. Percutaneous SI fusion remains experimental at this time.     

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of minimally invasive percutaneous sacroiliac (SI) fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal (D3320) for tooth # 21.  You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says root canal is not a covered dental 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 root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) for tooth # 21.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has multi-level disease, including moderate to severe central canal stenosis at L3-L4, the level requested for treatment. The record does not document that the enrollee is not indicated for operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz FX injection (CPT code J7321).

You asked the Plan to pre-approve the medication. You say that this medication is medically necessary. The Plan denied your request. The Plan says the request does not meet the step therapy criteria.

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 the medication. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve a Supartz FX injection (CPT code J7321).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (45378).

You asked the Plan to pre-approve Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed. You say that a colonoscopy is medically necessary. The Plan denied your request. The Plan says a colonoscopy is not medically necessary.

The Plan follows Medicare rules. 

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 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed. Our reviewer says that a colonoscopy is not medically necessary. Our physician reviewer found that the enrollee had a baseline colonoscopy in 2017. One 8 mm adenomatous polyp was removed on that study. The enrollee had her first surveillance colonoscopy on April 15.2021. Seven (7) adenomatous polyps were removed at that time including 1from the cecum, 1 from the ascending colon, and 5 from the descending colon. All but one were less than 10 mm. The cecal polyp was 15 mm and removed with piecemeal resection. Based on the US Multi-Society Task Force recommendations released in 2020, another surveillance colonoscopy would be indicated after a 3-year interval (based on the findings of more than 5 adenomas and the 1 larger adenoma >10 mm on her most recent study). This request is for a second surveillance study to be done with only a 6-month interval. The provider noted the 15 mm polyp removed with piecemeal resection as the reason for the 6-month interval. However, the Task Force recommends a 6-month interval for piecemeal resection only if the polyp is 20 mm or greater in size. The enrollee has no history of colon cancer and was not noted to have any high-risk genetic condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (45378).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).  

You asked the Plan to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625). You say that the requested Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625) is medically necessary. The Plan denied your request. The Plan says the requested Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625) is not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).  

Our reviewer says that the requested Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625) is not medically necessary. Our physician reviewer found sacroiliac joint radiofrequency ablation is experimental. More research is needed to show safety and efficacy of this procedure for back pain. The requested sacroiliac joint radiofrequency ablation is not 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 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625) have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (64625).