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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you will hurt yourself if you are left unattended without medical supervision. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 2, 2021.
You asked the Plan to pay for the refraction. You say that this was a check-up after cataract surgery and the $94 charge should be paid. The Plan denied your request. The Plan says a refraction is only covered as part of your routine eye exam every 12 months.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers a refraction as part of a routine eye exam every 12 months. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, the Plan paid for the refraction as part of the routine eye exam provided on February 2, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ziextenzo (Q5120).

You asked the Plan to pre-approve Ziextenzo. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not been met.

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 Ziextenzo. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Fulphila, Neulasta, or Udenyca before they will approve the requested drug, Ziextenzo. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Ziextenzo (Q5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visits. You say that the in-network provider does not have an oncologist available who can treat your type of cancer. 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. Therefore, we decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received on February 17, 2021.
You asked the Plan to waive the deductible for the lab services. You say that you checked to make sure that the provider was in-network and you also say that you had your blood drawn at the doctor's office. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on February 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services you received on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral carpal tunnel release (64721).
You asked the Plan to pre-approve a bilateral carpal tunnel release. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.
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 a bilateral carpal tunnel release. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Detailed documentation is not evident regarding electrodiagnostic studies having been performed to corroborate the bilateral pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bilateral carpal tunnel release have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral carpal tunnel release (64721).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (code D4921) and antimicrobial agents (code D4381).
You asked the Plan to pre-approve dental services. You say that the antibiotics are to keep an infection from occurring, and it is absurd that the Plan would deny these services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because gingival irrigation and dental antimicrobial agents are not covered by the Plan's dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (code D4921) and antimicrobial agents (code D4381).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the published clinical evidence does not show clear superiority of the requested procedure over standard surgical intervention. The requested procedure is still considered experimental/investigational. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from January 2, 2021, through February 27, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 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 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from January 2, 2021, through February 27, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided on March 27, 2021.
You asked the Plan to waive the deductible for inpatient hospital care. You say that you disagree with 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. Your contract with the Plan says that there is a $1,000 deductible which applies to out-of-network inpatient hospital care. You received inpatient hospital care at an out-of-network provider on March 27, 2021. The record shows that you had paid $474.49 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $161.15.
The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-network inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on March 27, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care provided on March 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional PT visits are medically 
necessary. The Plan denied your request. The Plan says eight (8) additional PT visits are not medically The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 eight (8) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that based on the medical records provided there is no 
documentation that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy 
and occupational therapy, by or under the supervision of a therapist. Based on the available records the enrollee 
appears to have had little improvement in pain and function with the sixteen (16) therapy sessions already 
provided. Further utilization of the home exercise program after completion of the six (6) additional approved 
therapy sessions appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional PT visits. 
necessary.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for teeth #5 and #21.

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the crowns 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 crowns 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 crowns. Our reviewer says that the requested crowns are not medically reasonable and necessary. Our physician reviewer found that tooth #5 has an existing crown that does not show any apparent marginal defects or decay. Tooth #21 appears to have an occlusal restoration and some distal decay which is small to moderate in size with no cuspal involvement. There is no documentation that indicates there is a defect of the existing crown on tooth #5 that would require replacement. Tooth #21 appears to be restorable with a conventional restoration. Given the lack of substantial damage to tooth #21, and lack of recurrent decay on the crown on #5, there is no medical necessity for new crowns.

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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns for teeth #5 and #21.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88305) provided on June 1, 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 there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (88305) provided on June 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93976) provided June 1, 2021.
You asked the Plan to pay for the duplex scan. You say that the service was medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and cannot be separately paid.
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, we have confirmed that code 93976 has a bundled relationship with code 76856 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (93976) provided June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation exceeding the Plan's 20-trip limit.
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to get to your appointments. The Plan denied your request. The Plan says you have exhausted your routine transportation benefit and additional trips are not covered under your benefits.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year.
We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that coverage has been provided for 20 trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation exceeding the Plan's 20-trip limit.
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 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 there is no documentation provided necessitating 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 present setting 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. 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 complete mandibular overdenture (D5865).

You asked the Plan to pre-approve the complete mandibular overdenture. You say that you are having trouble eating because you do not have a lower denture. The Plan denied your request. The Plan says this 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 a complete mandibular overdenture (D5865).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve neurostimulation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a BMI of 38.6, and the requirements are a BMI of less than 35. In addition, there is no clear documentation of CPAP failure. The notes indicate that you are unable to use CPAP because of discomfort, but there is no documentation of efforts to address the comfort of the interface. 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 neurostimulation.