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

We decided that the Plan does not have to pre-approve dental anesthesia services.
You asked the Plan to pre-approve the requested services. You say that there is no other provider that can
provide the services. The Plan denied your request. The Plan says the services are not covered.
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.
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental
anesthesia services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on January 24, 2020.
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the adjacent tissue transfer. Our reviewer says that CPT code 14040 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records documented that an extensive undermining and advancement of the wound edges was performed which does not meet the coding definition of CPT code 14040, therefore, it would not be appropriate to use CPT 14040 to represent the service performed We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14040) provided on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member requires acute inpatient rehab to increase independence and return home to her community with improved quality of life. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hypertension and recent back surgery. He is living at home receiving physical therapy and has persistent weakness and difficulty with daily function. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on November 3, 2020, to November 24, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you are on a fixed income and you cannot afford this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for each physical therapy session. The total amount you are being asked to pay is $200 ($40 x 5 sessions = $200). Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on November 3, 2020, to November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating hospital on May 20, 2020.
You asked the Plan to waive the coinsurance for a laparoscopy. You say that you paid $385. You say that you did not know that you would owe 30% of the cost. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 30% coinsurance for outpatient surgery/outpatient hospital. You have been asked to pay a 30% coinsurance of the allowed amount for a laparoscopy. The total allowed amount is $10,192.48. The total amount you are being asked to pay is $3,057.74 ($10,192.48 x 30% = $3,057.74). The correct coinsurance has been applied to the services that were provided. A laparoscopy falls within the outpatient surgery/outpatient hospital 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 coinsurance for an outpatient surgery provided by a participating hospital on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns.

You asked the Plan to pay for the crowns. You say that you feel these services should be classified as medical
and covered. The Plan denied your request. The Plan says you have been reimbursed the maximum dental
allowance of $1,000.

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 Plan offers a $1,000 allowance
every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract
clearly states that you are responsible for any amount above the dental coverage limit. The record shows that
you met the annual maximum benefit and your annual maximum benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit and x-rays you received on October 21, 2020.
You asked the Plan to pay for the chiropractic services. You say that you were told that this would be covered. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit and x-rays you received on October 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have
osteoporosis. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show
that the required drug would be contraindicated or less effective; therefore, the Prolia is not reasonable or
medically necessary at this time.
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 Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit, and an outpatient surgery provided by a participating provider.

You asked the Plan to waive the copayment for an emergency room visit and wound care. You say that you were there for 15 minutes. You say that you did not have a surgery performed. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $120 copayment for emergency car and a $200 copayment for an outpatient surgery.

You have been asked to pay $84.05 which is less than your copayment amount of $120 copayment for an emergency room visit and a $200 copayment for wound care. The total amount you are being asked to pay is $284.05 ($84.05 + $200 = $284.05). An emergency room visit falls within the emergency care benefit category and wound care falls within the outpatient surgery 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 emergency room visit, and an outpatient surgery provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TDAP immunization (90471, 90715).

You asked the Plan to pay for the TDAP immunization. You say that you would like reconsideration because you are being billed for the full cost. The Plan denied your request. The Plan says coverage for a tetanus vaccination is covered under Medicare Part B if it is related to an accidental puncture wound or injury.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP immunization. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the TDAP immunization. Therefore, we decided that the Plan does not have to pay for the TDAP immunization (90471, 90715).

Benefits for the TDAP immunization 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve CGM. You say that the enrollee has struggled to achieve adequate control of his condition. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not use insulin 3 or more times per day with frequent dosing adjustments.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Buprenorphine for the enrollee.

Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage IV recurrent unresectable squamous cell carcinoma of the hypopharynx. Keytruda is FDA-approved for the single-agent treatment of recurrent or metastatic head and neck squamous cell carcinoma in patients with disease progression on or after platinum-containing chemotherapy. There is no off-label support in the major drug compendia or medical literature. The enrollee is felt to be a poor candidate for platin-based therapy and the plan is for palliative Keytruda; however, he has a PD-L1 of 0 and is unlikely to have a meaningful response to Keytruda. Single-agent chemotherapy is the standard of care. The Keytruda is 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 Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261).

You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because the nearest in-network provider is 230 miles from your home. The Plan denied your request. The Plan says hearing aid services are only covered if the services are rendered in-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by a select provider.

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Please note, the Plan has verified that there are in-network providers within reasonable distance of your home. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services (97597) provided on November 20,
2020 by an out of network (OON) provider.
You asked the Plan to pay for the wound care services. You say that the facility is contracted-Par with the plan.
Due to the enrollee's condition and the pandemic coronavirus emergency. Please kindly review closely per your
contract and reconsider for payment. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the wound care services (97597) provided on
November 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on October 20, 2020.
You asked the Plan to pay for the dental service. You say that a plan representative advised that you were covered for a free exam, cleaning, and x-rays. You say that you called on 2 separate occasions and were given the same information both times. You say that you were unable to locate your 2020 Evidence of Coverage both times. You also say that the service should be covered based on what you were told. The Plan denied your request. The Plan says bitewing x-rays are 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, bitewing x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on July 23, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in one state while the member and laboratory are located in another state. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on July 23, 2020.
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 at LTACH the enrollee will receive nursing care, routine labs to monitor renal function, imaging to monitor pneumonia, and pulmonary rehabilitation to be weaned from oxygen. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 the enrollee appears to be improving but requires additional short-term acute care services which can be safely received at the current acute care hospital. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. The requested LTACH services will be considered not medically necessary at this time. Transfer may be considered soon when treatment has been completed. 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.