Persius/hicric huggingface dataset:
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 an LTACH is a more appropriate setting for the enrollee at this time. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving the appropriate care in the current setting; there is no advantage in moving the enrollee from the current acute care hospital to an LTACH.
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 admission to a LTACH. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network neurologist.
You asked the Plan to pre-approve the continuation of care with an out-of-network neurologist. You say that the requested continuation of care with the out-of-network neurologist is medically necessary. The Plan denied your request. The Plan says the requested continuation of care with the out-of-network neurologist is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continuation of care with an out-of-network neurologist. Our reviewer says that the requested continuation of care with the out-of-network neurologist is not medically necessary. Our physician reviewer found the member in this case has a longstanding history of epilepsy. While she has been prescribed medications, a continuation of medical management can be accomplished with a new provider. The member's condition is relatively common and is generally managed by most general neurologists. The management of epilepsy is a standard part of the general neurology practice. A new provider could continue to prescribe medications for the enrollee and/or suggest alternative treatment approaches. As noted above the member's pharmacotherapy can be transitioned to an in-network provider without any form of lapse of/in care. A new provider can continue to prescribe therapies which have been beneficial and/or suggest new therapies as needed. 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 continuation of care with an out-of-network neurologist have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care with an out-of-network neurologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular denture (D5140) and reline of a complete mandibular denture (D5751).

You asked the Plan to pre-approve the immediate mandibular denture and reline of a complete mandibular denture. You say that you only have 6 remaining teeth which are all in horrible condition. You also say that you do not have the estimated $5,000 it costs to replace your teeth. The Plan denied your request. The Plan says these services are not covered under your plan. The Plan also says that you currently are not enrolled in the dental platinum rider 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 immediate mandibular denture (D5140) and reline of a complete mandibular denture (D5751).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel for the enrollee.
You asked the Plan to pre-approve the testing. You say that a repeat test is being requested to re-assess the previously discovered mutations. The Plan denied your request. The Plan says this is not a covered test per Medicare.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing is unlikely impact therapeutic decision-making in the clinical management of the enrollee. The review has determined that the enrollee does not meet the criteria for this request. 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 pre-approve a targeted genomic sequence analysis panel for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014), an eye exam with photos (92250), a visual field exam (92083) and an ultrasound scan of the cornea (76514) provided on January 28, 2020.
You asked the Plan to pay for a medical eye exam, an eye exam with photos, a visual field exam and an ultrasound scan of the cornea. You say that you sent in the claim on time but when you did not receive a payment, you sent the claim in again. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for a medical eye exam, an eye exam with photos, a visual field exam and an ultrasound scan of the cornea was not filed until May 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a medical eye exam (92014), an eye exam with photos (92250), a visual field exam (92083) and an ultrasound scan of the cornea (76514) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has traumatic spondylopathy and post-laminectomy syndrome. Initial medial branch blocks (MBBs) at L5 to S1 were completed on May 18, 2021 with no second confirmatory set of injections. The criteria for coverage are not met and the RFA is therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.

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 medical records submitted do not document any of the covered diagnoses for this
therapy, or a trial and failure of standard wound therapy.

The Plan must follow Medicare rules. The rules say that hyperbaric oxygen therapy is only covered for certain
specific conditions.

The records do not show evidence of any of covered indications for this request. 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 hyperbaric oxygen therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 5, 2021.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is a duplicate claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal rights. 

We find that CPT code 99308 is not supported in the record. Specifically, the record shows that this is a duplicate claim. Another claim for the same member, provider, CPT code and date of service was processed and paid by the Plan. There is no indication in the record that this service was rendered multiple times on the same date. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hypnotherapy services (90880) provided May 24, 2021 to May 30, 2021.
You asked the Plan to pay for the hypnotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider at issue is not eligible for Medicare payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for hypnotherapy services (90880) provided May 24, 2021 to May 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on February 4, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245), two retainer crowns (D6740) and two core buildup procedures (D2950).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 a pontic (D6245), two retainer crowns (D6740) and two core buildup procedures (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing for 4 or more teeth per quadrant (D4341) for the lower left, upper left, and lower right quadrants.
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the services are not medically necessary.
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 dental services 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 the dental services. Our reviewer says that the scaling and root planing for the upper left, lower left and lower right quadrants are not medically necessary. Our physician reviewer found the periodontal charting does not include the implant teeth placed in the upper left quadrant. The reviewer found that there are three involved teeth in the lower left quadrant.
The reviewer found that there is one tooth in the lower right quadrant. Therefore, the reviewer found that the procedure code, D4341, is not medically necessary as there are less than 4 teeth in each quadrant that require treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), therapeutic parenteral
drug (D9610 x 2), removal of tooth roots (D7250 x 2), 1-surface filling for posterior tooth (D2391 x 5), and a
3-surface filling for anterior tooth (D2332).
You asked the Plan to pre-approve the dental services. You say that the fillings should be covered. You say that
you need these services to be complete before a bone marrow transplant can be performed. You also say that
you are requesting that an exception be made. The Plan denied your request. The Plan says 2 fillings are
covered per calendar year. The Plan says that the frequency limit has been reached. The Plan also says gingival
irrigation, therapeutic parenteral drugs, and removal of tooth roots are not listed as 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 and fillings are listed as covered, the
frequency limit has been reached. The record shows that the Plan approved fillings for teeth # 14 and 18.
Additionally, gingival irrigation, therapeutic parenteral drugs, and removal of tooth roots are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation
(D4921 x 4), therapeutic parenteral drug (D9610 x 2), removal of tooth roots (D7250 x 2), 1-surface filling for
posterior tooth (D2391 x 5), and a 3-surface filling for anterior tooth (D2332).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that the enrollee needs this for age-related osteoporosis. The Plan denied your request. The Plan says that this is not covered under Part B.
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 brought to the office for administration. 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 Prolia for the enrollee.
Benefits for Prolia 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit 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 current information does not show a trial and failure of the preferred step therapy
drug Retacrit.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial
of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the
required drugs. There is no documentation provided indicating that the plan's required drug would likely be
less effective and/or likely have adverse effects for the enrollee.

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 Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair for use outside of the home.
You asked the Plan to pre-approve a transport chair. You say that the current wheelchair you have is too heavy to move in and out of the home. The Plan denied your request. The Plan says you have a wheelchair for use in the home. Duplicate equipment or equipment for use outside of the home is not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item requested is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transport chair for use outside of the home.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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, home with home health services or home with outpatient therapy.
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 skin grafting surgery to treat a burn of the hand. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical decision support mechanism services rendered on
March 19, 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 procedure code G1004 is not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.

We looked at the file and Medicare rules. Billed procedure code G1004 (clinical decision support mechanism
national decision support company, as defined by the Medicare appropriate use criteria program) has a status
indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not
have to pay for the clinical decision support mechanism services rendered on March 19, 2021.