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

We decided that the Plan does not have to pre-approve an extracranial bilateral study (93880).

You asked the Plan to pre-approve an extracranial bilateral study. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
service.

The Plan follows Medicare rules. Medicare rules say that an extracranial bilateral study is covered for certain 
medical 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 an extracranial bilateral study. Our 
reviewer says that an extracranial bilateral study is not medically necessary at this time. Our physician reviewer 
found documentation does not support the rationale for this imaging study. Guidelines do not support a need 
for bilateral carotid duplex scan extracranial study. As a result, at this time cardiac doppler imaging would not 
be considered medically appropriate and necessary in this patient's clinical management.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an extracranial bilateral study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an extracranial bilateral study (93880).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C.
You asked the Plan to pre-approve Gamunex-C. You say that this is medically necessary. 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. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
administered in the home. Since the medication does not represent an expense to the physician and will not be
included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does
not have to pre-approve Gamunex-C.
Of note, the Plan has agreed to coverage under Medicare Part D.
Benefits for Gamunex-C 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG provided on July 15, 2021.
You asked the Plan to waive the copayment for an EKG. You say that you cannot afford the charges. The Plan
denied your request. The Plan says the claims were processed correctly, and you are being charged the correct
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for outpatient diagnostic tests.
You have been asked to pay a $10 copayment for an EKG. An EKG falls within the outpatient diagnostic tests
and therapeutic services and supplies benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for an EKG provided on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Femtosecond Laser cataract removal on March 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that beneficiaries are responsible for payment of
laser-assisted cataract surgery beyond what Medicare covers.
We looked at the file and Medicare rules. The file shows that you received laser-assisted cataract surgery.
Medicare does not cover the laser-assisted portion of the surgery. The file also shows that you signed a claim
form acknowledging that you would be financially responsible for the non-covered charges. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for the Femtosecond Laser cataract removal on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).
You asked the Plan to pre-approve the incisional biopsy. You say that you have not been able to get dentures
because there is an extra growth on the top of the roof of your mouth that has to be completely removed before
anything else. The Plan denied your request. The Plan says this service is not covered under your 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 an
incisional biopsy of oral tissue (D7286).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) provided on
August 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization was not obtained
prior to this enrollee being seen because it is the nursing facility's responsibility to get authorizations for their
patients. You also say that it was medically necessary for the enrollee to receive the treatment, and you did not
know that the facility had failed to get prior authorization for this enrollee. The Plan denied your request. The
Plan says this service was rendered by an OON provider, and the services rendered were not plan directed care.
The Plan also says that prior authorization was not 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.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99326)
provided on August 20, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care provider visit provided on
September 13, 2021.
You asked the Plan to waive the copayment for a primary care provider visit. You say that you were told that
you would not owe a copayment for this service. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for primary care provider visits.
You have been asked to pay a $20 copayment for a primary care provider visit. A primary care provider visit
falls within the physician/practitioner services, including doctor's office visits benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for a primary care provider visit provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with drug testing (99214, G0483, 80307) provided on March 16, 2021, by an out-of-network (OON) provider
You asked the Plan to pay for an office visit with drug testing. You say that you did not know that the patient was with this Plan until he informed you on March 2, 2021. You also say that you signed a contract in 2019 with the Plan, so you assumed your providers were still in-network. The Plan denied your request. The Plan says this provider is a non-participating provider with the Plan. The Plan also says they did not authorize any services for this 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 an office visit with drug testing (99214, G0483, 80307) provided on March 16, 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 insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the results of the
study show that patients demonstrated clinical success on at least two of the three domains. You say that the
Vertiflex Superion device shows definite medical health benefits for spinal stenosis. The Plan denied your
request. The Plan says the requested CPT code 22869 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 the insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the Interspinous process stabilization devices remain
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 insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7285).
You asked the Plan to pre-approve the incisional biopsy. You say that you were advised by your oral surgeon
that the area appears suspicious. You also say that you were told the area of concern looks like it is about to
erupt and may cause an infection. The Plan denied your request. The Plan says this service is not covered under
your benefit package.
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 an
incisional biopsy of oral tissue (D7285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
LTACH services.

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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care.

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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops, for the enrollee
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee does not have pharmacy (drug) benefits administered by this health
plan. The Plan states the enrollee has prescription coverage through another 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 Xiidra 5% drops, for the enrollee
Benefits for the medication 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: 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 enrollee needs continued ventilation
management with weaning. The Plan denied your request. The Plan says the guidelines for coverage have not
been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.
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 there is no documentation provided indicating medical necessity for LTACH
services.
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require
services at the LTACH that are not available at the acute care hospital where she is currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954)
and to pay more for the crown (D2740) provided on September 8, 2021.
You asked the Plan to pay for the prefabricated post and core or pay more for the crown. You say that you
believe both the prefabricated post and core and crown procedures were combined into code D2954, which is
not covered by the Plan. You also say that you believe the Plan needs to cover 30% of the crown procedure
(D2740) and you will be responsible for the balance of your dental bill. The Plan denied your request. The Plan
says the prefabricated post and core is not a covered expense under your dental plan, and the crown was
processed according to the Plan's negotiated rate. The Plan also says that you did not contact the Plan prior to
this date of service to verify benefits and provider eligibility.
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, prefabricated post and core in addition
to crown (D2954) is not among those covered under this benefit. The Plan contract says that you are
responsible for a 70% coinsurance for crowns that are received in-network. Therefore, we decided that the Plan
does not have to pay for the prefabricated post and core in addition to crown (D2954) and to pay more for the
crown (D2740) provided on September 8, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition., The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 There is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis.

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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211) to be provided by an out of network dentist.

You asked the Plan to pre-approve the dental service. You say that you have not been able to fine an in network dentist that is able to make a partial denture for you. You say that you have spoken to 3 plan representatives trying to find an in network dentist. You also say that your partial denture has been broken for 6 months and you need it fixed as soon as possible. The Plan denied your request. The Plan says there are in network dentists that can provide this 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 out of network dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5211) to be provided by an out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the lumbar facet joint injection is considered not medically necessary at this time and cannot be approved.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has radiculopathy. The review has determined that the enrollee does not meet the criteria for this request. The requested procedure 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 therapeutic facet joint injection for the enrollee.