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

We decided that the Plan does not have to pay for the crown for tooth #7 provided on April 6, 2021.
You asked the Plan to pay for the crown for tooth #7. You say that the crown was necessary to fix your tooth
due to decay under the previous filling. You say that you would not have had the crown done if you knew it
was not going to be covered. The Plan denied your request. The Plan says the documentation shows tooth #7
does not demonstrate an extensive loss of tooth structure to justify crown coverage.
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 for
tooth #7 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 for tooth #7. Our reviewer says
that the provided records are insufficient to establish the presence of the extensive loss of tooth structure to
necessitate a crown under plan rules. Our physician reviewer found that the elements of the coverage criteria
are not satisfied, and 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
the Plan's rules for coverage of the crown for tooth #7 have not been met. Therefore, we decided that the Plan
does not have to pay for the crown for tooth #7 provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81291 and 81479) provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like reconsideration because this testing is covered by Medicare. The Plan denied your request. The Plan says the healthplan requires utilization of network providers when possible and available, and requires authorization for certain services.
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. Additionally, the present evidence does not clearly demonstrate that routine PGx testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81291 and 81479) provided on January 29, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection between the approved wheelchair's drive control and the power tilt seating system (coded as E2310).
You asked the Plan to pre-approve the electronic connection. You say that the requested items should be approved. The Plan denied your request. The Plan says all requested components were approved, but the connection to allow control of the power tilt actuator from the joystick is not reasonable and 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 the electronic connection. Our reviewer says that the requested electronic connection is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is able to access and manipulate the power tilt actuator according to the notes.
Although it appears that the patient warrants a power wheelchair with power lift, the joystick control is not supported by the documentation, and therefore, will be considered 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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection between the approved wheelchair's drive control and the power tilt seating system (coded as E2310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services with DRG 543 provided on 
August 5, 2020, through August 11, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support DRG 543. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N39.0 and E87.1. 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 inpatient hospital services. Our reviewer says that the review supports DRG 
544. Secondary diagnosis code assignment of N39.0, Urinary tract infection, site not specified and E87.1, 
Hypo-osmolality and hyponatremia were reported by the hospital. According to coding guidelines and 
documentation in the medical record this condition did not qualify for report. Our physician reviewer found the 
documentation was inconsistent/unclear regarding diagnoses of urinary tract infection and hyponatremia. Even 
though urinary tract infection is documented on H&P, progress notes and discharge summary, supporting 
medical record documentation was not found within the record. Hyponatremia was documented as mild 
hyponatremia, though sodium level was 133 on presentation there was lack of further investigation regarding 
the diagnosis of hyponatremia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services with DRG 543 provided on August 5, 2020, through August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve power operated vehicle. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be obtained from an in-network equipment supplier.
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 a power operated vehicle to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival flap procedure.

You asked the Plan to pre-approve the gingival flap procedure. You say that the situation will get worse if it's not corrected and you do not want to lose your tooth. The Plan denied your request. The Plan says the service is not a covered 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 pre-approve the gingival flap procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 2), pontic (D6245), and occlusal guard (D9945).

You asked the Plan to pre-approve the dental services. You say that it is recommended the enrollee get an occlusal guard to prevent further fractures or cracks on current teeth. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service. The Plan says that occlusal guard is not listed as a covered dental item 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, pontic, and occlusal guard are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740 x 2), pontic (D6245), and occlusal guard (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you have a genetic disease, and this is the only provider who can treat you. 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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for tooth # 3 and # 30.
You asked the Plan to pre-approve core buildup for tooth # 3 and # 30. You say that you are on social security
with many bills and would like the charge waived. The Plan denied your request. The Plan says the service is
not a covered 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 pre-approve core
buildup for tooth # 3 and # 30.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits and the lesion destruction provided on May 17, 2021 to June 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visits and the lesion destruction. You say that the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the home visits and the lesion destruction provided on May 17, 2021 to June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
You asked the Plan to pre-approve personal care services. You say that you need to get in home health support services. The Plan denied your request. The Plan says personal care services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) 
procedure. 
 
You asked the Plan to pre-approve the PVA procedure. You say that the enrollee would benefit from this 
procedure to treat ongoing pain. The Plan denied your request. The Plan says the notes did not show that 
osteoporosis education is planned. Therefore, this treatment cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered for treatment of VCF when there is a 
failure of conservative management.  
 
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 PVA procedure. Our reviewer says 
that the requested procedure is not considered medically necessary at this time. Our physician reviewer found 
the prior conservative treatment of the patient's VCF is not adequate as there was not a trial of bracing. 
 
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 PVA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous vertebral augmentation (PVA) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a raised toilet seat received on March 5, 2021. 
 
You asked the Plan to pay for a raised toilet seat. You say that you feel this item should be covered. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat received on March 5, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided on
April 16, 2021, by an OON provider.
You asked the Plan to pay for the chiropractic services. You say that this appeal has been sent because the
authorization department had advised it. Please review. The Plan denied your request. The Plan says enrollee's
must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
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 chiropractic manipulative treatment (98940)
provided on April 16, 2021, by an OON provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had sufficient time with Retacrit to determine responsiveness.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Reblozyl is indicated for treatment of anemia due to myelodysplastic syndromes with ring sideroblasts or myelodysplastic or myeloproliferative neoplasm with ring sideroblasts and thrombocytosis. There is no indication in the available records that the enrollee has ring sideroblasts or ring sideroblasts and thrombocytosis.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided you only require short-term additional acute
care services that can safely be administered at the current facility. You do not require services at the LTACH
that are not already available at the current facility. There are no services at the LTACH that you require that
are not already available and covered at the current facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for a right leg percutaneous arteriogram and possible revascularization (CPT code(s): 35371 and 75710).
You asked the Plan to pre-approve acute inpatient hospital care. You say that the surgery was approved at an observation level of care. You state you disagree with it due to several complicated medical conditions that you have. The Plan denied your request. The Plan says the information does not show you need an inpatient level of care for your right leg percutaneous arteriogram and possible revascularization. The Plan states your right leg percutaneous arteriogram and possible revascularization, however, may be performed at an observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that the admitting physician reasonably expects that your necessary hospital care will span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for a right leg percutaneous arteriogram and possible revascularization (CPT code(s): 35371 and 75710).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injection.
You asked the Plan to pre-approve Praluent. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Praluent injection.
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.