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

We decided that the Plan does not have to pre-approve sacroiliac joint nerve blocks and bilateral lumbar
transforaminal epidural injections.
You asked the Plan to pre-approve sacroiliac joint nerve blocks and bilateral lumbar transforaminal epidural
injections. 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 follows Medicare rules. Medicare rules say that injection services are only covered for certain
indications. 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 sacroiliac joint nerve blocks
and bilateral lumbar transforaminal epidural injections. Our reviewer says that the documentation does not
support that the requested services are medically reasonable or necessary. Our physician reviewer found the
enrollee has complaints of low back pain radiating into the sacrum and bilateral buttocks. The pain is
accompanied by numbness/tingling with radiation to the left lower extremity anteriorly to dorsal aspect of left
foot. The enrollee has tried and failed conservative treatment. The pain continues to impede on activities of
daily living performance and quality of life. There is no documentation of a plan of care to perform the services
requested. The services being requested on initial review and on appeal do not correspond to the services the
provider plans to perform. Multiple outreach attempts have been made to the provider's office to clarify and
possibly correct the submitted codes, to either obtain updated clinical records to support the requested codes, or
to correct the codes to match the requested service of the coccyx somatic nerve block. Therefore, the enrollee
does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint nerve blocks and bilateral lumbar transforaminal epidural
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint
nerve blocks and bilateral lumbar transforaminal epidural injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271), 200 mg every 21 days.
You asked the Plan to pre-approve Keytruda. You say that there is evidence of progression within the liver while on Taxotere and prednisone. The Plan denied your request. The Plan says the requested drug is not indicated for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the requested drug, Keytruda, is not medically necessary. Our physician reviewer found requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The reviewer found that the provided documentation does not indicate that the tumor has not been shown to be microsatellite instability (MSI) high or deficient MisMatch Repair (dMMR). The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that Keytruda 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 Keytruda have not been met. Specifically, the file does not show that the tumor
has not shown to be MSI high or dMMR. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271), 200 mg every 21 day
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a primary closure of a sinus perforation (D7261) and bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the primary closure of a sinus perforation and bone replacement graft. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a primary closure of a sinus perforation (D7261) and bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that further physical therapy can be very beneficial. The Plan denied your request. The Plan says you are unable to tolerate daily therapy.

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 physician reviewer found that from a nursing perspective, you received oral medications, and had ongoing orthostasis. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a maximal assist level for bed mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (D4261), and repair of maxillofacial soft and/or hard tissue defect (D7955) provided on March 17, 2021.

You asked the Plan to pay for osseous surgery, and repair of maxillofacial soft and/or hard tissue defect. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue 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 pay for osseous surgery (D4261), and repair of maxillofacial soft and/or hard tissue defect (D7955) provided on March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta (belimumab) (Q1051).

You asked the Plan to pre-approve Benlysta. You say that the enrollee is not able to trial nonsteroidal antiinflammatory
drugs (NSAIDs) due to their advanced age. The Plan denied your request. The Plan says the
provided documentation did not show that the requested drug is being provided in combination with standard
therapy.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Benlysta. Our reviewer says that the
requested drug, Benlysta, is not medically necessary. Our physician reviewer found the requested drug,
Benlysta, is Food and Drug Administration-approved for treatment of the enrollee's diagnosis when used in
combination with standard therapy. The reviewer found that the provided medical records do not clarify that
the Benlysta, in this case, will be used in combination with standard therapy. Therefore, the reviewer found that
Benlysta is not medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Benlysta have not been met. Specifically, the file does not show that the
enrollee will be taking the drug in combination with standard therapy. Therefore, we decided that the Plan does
not have to pre-approve Benlysta (belimumab) (Q1051).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oral Ensure nutritional drinks.

You asked the Plan to pre-approve Oral Ensure nutritional drinks. You say that this is medically necessary for
your condition. The Plan denied your request. The Plan says nutritional supplements are not covered by
Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan
does not have to pre-approve Oral Ensure nutritional drinks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for standard frames (V2020), and progressive lenses (V2781) received on April 30, 2021.
You asked the Plan to pay for standard frames, and progressive lenses. You say that the services should be covered. The Plan denied your request. The Plan says the benefit maximum allowance had already been met.
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. The Plan covers these services up to a $200 allowance every 2 years. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of standard frames, and progressive lenses have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum on January 13, 2020. Therefore, we decided that the Plan does not have to pay for standard frames (V2020), and progressive lenses (V2781) received on April 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new prosthetic leg replacement.
You asked the Plan to pre-approve a new prosthetic leg replacement. You say that this request is medically necessary for the enrollee's changing condition. The Plan denied your request. The Plan says the medical records submitted do not indicate why the current leg prosthetic is not capable of treating the enrollee's condition.
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. In addition, the rules say that replacement of a prosthesis is covered when Medicare rules are met. In this case, the medical records located in the file do not adequately demonstrate that the enrollee's medical condition has changed enough to warrant a replacement prosthetic. Without proof that the enrollee's condition has changed, coverage will not be provided for a replacement leg prosthetic. Therefore, we decided that the Plan does not have to pre-approve a new prosthetic leg replacement.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) rendered by the out-of-network (OON) provider on April 6, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography (93306) rendered by the out-of-network (OON) provider on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia
(D9222), each subsequent 15-minute increment of deep sedation/general anesthesia (D9223) or pay more for
the surgical extraction (D7210) provided on April 16, 2021, by an OON provider.

You asked the Plan to pay for the deep sedation/general anesthesia and to pay more for the surgical extraction.
You say that your doctor recommended you have your tooth extracted by this oral surgeon. The Plan denied
your request. The Plan says the deep sedation/general anesthesia is not covered under your dental plan. The
Plan also says that for covered services obtained OON the Plan only pays up to a certain amount, and you may
be billed for any amount greater than what the Plan pays.

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, first 15 minutes of deep
sedation/general anesthesia (D9222) and each subsequent 15-minute increment of deep sedation/general
anesthesia (D9223) are not among those covered under this benefit. You are also responsible for the difference
between the billed amount and allowed amount for covered dental services received OON. Therefore, we
decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia (D9222),
each subsequent 15-minute increment of deep sedation/general anesthesia (D9223) or pay more for the surgical
extraction (D7210) provided on April 16, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lens provided on February 25, 2021.

You asked the Plan to pay for the frames and lens. You say that you want the Plan to cover the eyeglasses. The Plan denied your request. The Plan says this provider is an out-of-network provider and you do not have out-of-network benefits.

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. The Plan covers these services when they are received from a network provider. 

We looked at the file and the Plan's rules. The frames and lens were received from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the frames and lens have not been met. Therefore, we decided that the Plan does not have to pay for the frames and lens provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and topical application of fluoride (D1206) provided on April 26, 2021.
You asked the Plan to pay an additional amount for a comprehensive oral evaluation, a teeth cleaning, and topical application of fluoride. You say that the services should be covered. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation, a teeth cleaning, and topical application of fluoride have not been
met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan.
Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan
does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning
(D1110), and topical application of fluoride (D1206) provided on April 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need to continue your physical
rehabilitation. The Plan denied your request. The Plan says you do not need daily skilled nursing or
rehabilitation therapy.
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 physician reviewer
found that from a nursing perspective, you received oral medications and had stable vital signs. There are no
identifiable skilled nursing service needs. Regarding rehab services, you were at a modified independent to
independent level with functional mobility. You were independent with most activities of daily living. There
are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF
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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 22, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that the office staff told you they verified everything with your insurance company. You also say that you cannot pay this bill, and it was the office's mistake to not verify everything was correct with your insurance. The Plan denied your request. The Plan says these services exceed the frequency limitations in 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on October 26, 2020 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 22, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve azathioprine (J7500).

You asked the Plan to pre-approve azathioprine. You say that the enrollee has been on this medication for 6
years. The Plan denied your request. The Plan says the enrollee has not had a transplant. The Plan says that the
requested drug is not covered under the medical benefit. The Plan says that the requested drug is considered
self-administered in this situation. The Plan also says self-administered drugs are covered under a Medicare
Part D 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 azathioprine (J7500).

Benefits for azathioprine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a positron emission tomography (PET) with concurrently
acquired computed tomography (CT).
You asked the Plan to provide a PET with CT for attenuation correction and anatomical localization imaging;
whole body (78816). You say that the enrollee needs a PET scan. The Plan denied your request. The Plan says
the PET CT is being requested as part of the initial treatment strategy.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to provide a PET with CT for attenuation correction
and anatomical localization imaging, whole body (78816). Our reviewer says that the PET CT is not medically
reasonable or necessary. Our physician reviewer found none of the prostate-specific PET tracers is approved in
the setting of initial staging of prostate cancer, only for diagnostic evaluation of men with a rising prostatespecific
antigen (PSA) after initial definitive treatment. This patient has not had a biopsy and although strong
suspicion of prostate cancer the diagnosis has not been confirmed. A PET scan is 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 a PET with CT for attenuation correction and anatomical localization imaging;
whole body (78816) have not been met. Therefore, we decided that the Plan does not have to provide a positron
emission tomography (PET) with concurrently acquired computed tomography (CT).