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

 We decided that the Plan does not have to pre-approve Rituxan for the enrollee.  You asked the Plan to pre-approve the enrollee. You say that this is medically necessary. The Plan denied your request. The Plan says there is no compendia support for use of Rituxan for connective tissue disease and interstitial lung disease.  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 enrollee. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has mixed connective tissue disease with interstitial lung disease. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition  The Medicare approved  drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Additionally, upon reconsideration, the provider has indicated that the diagnosis is myasthenia gravis. The documentation provided does not support the newly indicated diagnosis, and is not credible. Notwithstanding that fact, the requested drug is subjected to step therapy. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative.  The elements of the coverage criteria are not satisfied.  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 enrollee have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from July 22, 2021, to July 30, 2021.  You asked the Plan to pay for IRF care. You say that the enrollee should be reimbursed for the services. The Plan denied your request. The Plan says the IRF care is not medically necessary.  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 pay for 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 provided documentation indicates that the enrollee is medically stable and does not have skilled needs. The reviewer found that the enrollee does not require an intensive rehabilitation therapy program. The reviewer also found that there is no reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the IRF services were 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from July 22, 2021, to July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on August 27, 2021.  You asked the Plan to pay for the dental service. You say that this should be paid for your exam and x-ray. You say that the services were necessary to determine your problem. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered 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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601) as billed with the NU modifier provided on March 31, 2021.  You asked the Plan to pay for the CPAP device as billed. You say that this item was medically necessary as documented by the medical records. The Plan denied your request. The Plan says this claim has been billed incorrectly and requires corrections.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also indicate that claim lines for coverage beyond the first three months of CPAP therapy must be billed with a GA, GZ, or KX modifier.  We find that CPT code E0601 as billed with the NU modifier is not eligible for payment. Specifically, this claim is missing a modifier that is required for coverage to be approved. If the criteria for coverage for continued use of the CPAP equipment was met, the claim should have been billed with the KX modifier. Based on this information, we decided that Medicare rules for coverage of the CPAP device as billed have not been met. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601) as billed with the NU modifier provided on March 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy.  You asked the Plan to pre-approve the referral. You say that you do not agree with this decision. The Plan denied your request. The Plan says there are in-network providers who can provide the 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 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 an out-of-network referral for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve orthopedic 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 services are medically necessary. The Plan denied your request. The Plan says the services are non-emergent. There are 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve orthopedic office visits 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 pay an additional amount for the partial lower denture (D5214) provided on August 24, 2021.  You asked the Plan to pay an additional amount for the dental item. You say that you needed dentures. You say that you were not able to chew. You also say that your allowance did not fully cover the services you received. The Plan denied your request. The Plan says there is a combined allowance of $2,000 for covered dental services. The Plan also says that the allowance was exceeded in the processing of this claim.  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 the lower denture is listed as a covered service, the yearly allowance has been exhausted. The record shows that the Plan paid $155 for dental services received on April 30, 2021, $180 for dental services received on July 5, 2021, and $1,665 for dental services received on the date of service in this case. $155 + $180 + $1,665 = $2,000. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay an additional amount for the partial lower denture (D5214) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 30, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that $195 is a lot for someone like you who is on a fixed income. You also say that you were trying to do the right thing and did not know the insurance would not pay for a second opinion. The Plan denied your request. The Plan says your cost share for these services cannot be waived. The Plan also says that you are responsible for the $133.00 cost share for these 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, you are limited to 1 oral exam every 36 months and 1 dental x-ray(s) per year. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on September 1, 2021, which processed and paid prior to the August 30, 2021 date of service, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922).  

You asked the Plan to pre-approve placement of biological dressing. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by your 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 placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan (72171) provided on May 12, 2021  

You asked the Plan to waive the copayment for the CT scan. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a CT scan on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  

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 $110 copayment for Advanced Imaging Services when provided in an outpatient hospital facility.     

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT scan on May 12, 2021. You have been asked to pay a $73.16 copayment for the CT scan, which is less than the contracted $110 copayment amount. The CT scan falls within the Outpatient diagnostic tests 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 the computed tomography (CT) scan (72171) provided on May 12, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel provided on June 2, 2021. 

 You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this testing is not covered by Medicare.
 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  

The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for facet joint ablation (64633, 64634).  

You asked the Plan to pay for facet joint ablation. You say that this is a different spinal section from the previous procedure. The Plan denied your request. The Plan says the requirements for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic medical branch blocks (MBBs). 
 
We looked at the file and Medicare rules. The record does not indicate that the enrollee has had at least 2 MBBs. Based on this information, we decided that Medicare rules for coverage of facet joint ablation have not been met. Therefore, we decided that the Plan does not have to pay for facet joint ablation (64633, 64634).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve blood glucose test strips (A4253) and lancets (A4259).  

You asked the Plan to pre-approve blood glucose test strips and lancets. You say that you have issues with your blood sugar which is why you received the prescription for the requested items from your doctor. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.  

The Plan must follow Medicare rules. Medicare rules say that, to be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must have diabetes.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blood glucose test strips and lancets have not been met. Specifically, the provided medical documentation does not support that you have diabetes. Therefore, we decided that the Plan does not have to pre-approve blood glucose test strips (A4253) and lancets (A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a wheelchair ramp.

You asked the Plan to pre-approve a wheelchair ramp. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an extra-wide heavy-duty hospital bed (E0303).  You asked the Plan to pre-approve an extra-wide heavy-duty hospital bed. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an extra-wide heavy-duty hospital bed have not been met. Specifically, the provided medical records indicate that your weight is not greater than 350 pounds. Therefore, we decided that the Plan does not have to pre-approve an extra-wide heavy-duty hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and implant supported porcelain/ceramic crown (D6065).  

You asked the Plan to pre-approve the prefabricated abutment and implant supported porcelain/ceramic crown. You say that you feel that if crowns are covered you should at least get credit for the typical price of a regular crown. The Plan denied your request. The Plan says these services are 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 a prefabricated abutment (D6056) and implant supported porcelain/ceramic crown (D6065).
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 a crown (D2954) provided on June 8, 2021.  You asked the Plan to pay for the dental service. You say that the Explanation of Benefits indicates that your share would be $153 for the service and that it was denied. You say that the dental provider sent you a bill for $275. You also say that your past experience is that other dental providers had an agreed upon payment amount for services is the same whether it is paid by insurance or not. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown is not listed as a covered 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 post and core in addition to a crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954) provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex superion device.  You asked the Plan to pre-approve Vertiflex superion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex superion device. 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 spinal stenosis. The vertiflex device is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device.