Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740 x4), and core buildups (D2950 x4).
You asked the Plan to pre-approve crowns, and core buildups. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the criteria is not met for coverage for the services at issue.
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 crowns, and core buildups 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 pre-approve crowns, and core buildups. Our reviewer says that the documentation provided does not meet the criteria for coverage for crowns or core buildups. Our physician reviewer found the periodontal condition of tooth #2 is questionable with more than 50% bone loss noted on x-ray, making the long-term prognosis. The amount of missing or damaged structure of tooth #2 is not extensive and would not require a crown restoration to restore any carious lesions that may exist. Teeth #4, 5, and 6 also do not exhibit any extensive breakdown from prior restoration or caries and would not require a full coverage crown restoration to repair any defects found on these teeth. Tooth #8 has damage especially at the cervical region, and about 50% bone loss. There is no incisal damage to the tooth and less than 50% of the structure has been compromised by decay or fracture. As none of the teeth have shown that there is
extensive damage to the coronal structure and no cusps or incisal edges are involved, there would be no medical necessity for crowns, or core buildups, for the requested teeth. 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 crowns, and core buildups have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x4), and core buildups (D2950 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on March 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the injection services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for the services rendered by an OON provider.
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 the injection services provided on March 31, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there appears to be some concern that the devices are not as effective as surgical 
decompression and lead to higher rates of reoperation. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulator (64568, 0466T).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that the BMI is too high.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the BMI must be less than 35, and your BMI is 40. The criteria are not met. 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 hypoglossal nerve stimulator (64568, 0466T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says completed studies say that this procedure does not improve outcomes compared to standard treatment.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Imfinzi.

You asked the Plan to pre-approve Imfinzi. You say that this is medically necessary for the enrollee's treatment and she is not enrolled in a clinical trial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee is enrolled in a clinical trial (trial NCT 04267848) so this drug would be a routine cost covered by Original Medicare.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Imfinzi as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve use of Imfinzi.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the mileage coded A0425 provided on April 7, 2021.
You asked the Plan to pay for the mileage. You say that the services were billed correctly. The Plan denied your request. The Plan says that fractional mileage units required.
The Plan must follow Medicare rules. Medicare rules say that miles must be billed in whole numbers. We looked at the file and Medicare rules. Review of the file shows that you billed a whole number of 7 for units billed for mileage. Based on the Medicare rules, this is the correct billing of miles for ambulance transportation. Based on this information, we decided that Medicare rules for coverage of the mileage have been met. Therefore, we decided that the Plan has to pay for the mileage coded A0425 provided on April 7, 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.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for non-surgical management of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on February 23, 2021.
You asked the Plan to pay for the anesthesia services. 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 payable.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that payment for this code is always bundled into payment for other services not specified and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one additional resin-based composite (D2391) or pay more for the one additional crown (D2740) provided on March 11, 2021.

You asked the Plan to pay for the one additional resin-based composite (D2391) and to pay more for the one additional crown (D2740). You say that you believe these services should be covered. The Plan denied your request. The Plan says the Health Plan has paid the maximum amount of $2,500 for your non-Medicare covered dental services.

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 Plan offers up to $2,500 every year for non-Medicare covered preventive and comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing the claim for the March 11, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the one additional resin-based composite (D2391) or pay more for the one additional crown (D2740) provided on March 11, 2021.

Please Note: The claim for the January 20, 2021 date of service does not need a decision. The Plan says that this date of service is not eligible for appeal because the claim was paid with no member cost share. Please contact the Plan if you have any questions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMdx testing provided on April 28, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ConfirmMdx testing is covered for the indications established in the applicable LCD. 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 testing. Our reviewer says that the requested testing is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 66-year-old male with an elevated prostate specific antigen. He had an initial prostate biopsy on April 28, 2021. Subsequent pathology report on May 4, 2021, revealed cellular atypia consisting of atypical small acinar proliferation at right lateral and left apex. The enrollee does not meet criteria for the requested test due to recent biopsy revealing cellular atypia. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMdx testing provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time coded as 99072 provided from January 27, 2021, to February 25, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these claims are always bundled into payment for other services.
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 99702 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99702 is not supported in the medical record. Specifically, CPT code 99702 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99702. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time coded as 99072 provided from January 27, 2021, to February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81227, 81225, 81223, 81226) provided May 18, 
2021. 
 
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 documentation does not support the billed services. 
 
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 code 81227, 81225, 81223, & 81226 is not supported in the medical record. Specifically, in 
this case a single lab procedure provided multiple results. A single CPT code should be billed for this service 
per the CMS National Correct Coding Initiative Coding Policy Manual for Medicare Services, Ch. X, Page 5. 
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 (81227, 81225, 81223, 81226) 
provided May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says the effectiveness of genicular nerve blocks in the setting of chronic knee osteoarthritis has not demonstrated in the peer-reviewed literature.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of the knee 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid flow/fluid GF injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be an off-label use of this medication, and the FDA has specifically warned about using stem cells in unapproved locations. The request 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid flow/fluid GF injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on July 13, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you would like to appeal these services. The Plan denied your request. The Plan says the maximum allowed for these services has been met. The Plan also says that there were no calls from you or the provider to the Plan asking about your benefit limitations.

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, oral evaluations are limited to once per year and panoramic x-ray (D0330) is limited to once per 36 months. The record shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) with another provider on June 23, 2021 and your oral exam and panoramic x-ray benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on July 13, 2021.