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

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). You asked the Plan to pre-approve a total knee arthroplasty. You say that the enrollee's osteoarthritis has interrupted her everyday life.The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a total knee arthroplasty is covered only when three or more of the above listed 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 a total knee arthroplasty. Our reviewer says that the criteria for coverage of a total knee arthroplasty have not been met. Our physician reviewer found there is no documentation of 3 months or more of non-surgical management. It is noted that the enrollee takes over the counter medication occasionally. There is no documentation of flexibility and muscle strengthening exercises and/or supervised physical therapy. There is also no documentation of functional disability despite compliance with a plan of care and no distinct structural abnormalities are identified. The enrollee does not have a failed previous joint replacement/arthroplasty that necessitates revision. A total knee arthroplasty is not medically reasonable and necessary for the enrollee 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 a total knee arthroplasty have not been met.Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).
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.You asked the Plan to pre-approve IRF care. You say that the claim should be approved.The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria and their needs can be met 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 above.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on September 13, 2018.
You asked the Plan to waive the copayment for the medical eye exam. You say that the insurance has not paid for this visit and you have been approved for the visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye for all other Medicare-covered vision services. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows diagnoses of visual disturbances, disorders of lacrimal system, conjunctivitis, and disorders of eyelid, which makes the eye exam medical in nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a medical eye exam provided on September 13, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on April 22, 2018 through April 30, 2018.You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the fifth position of the HIPPS code is billed with a value of S for non-routine supplies (NRS) and no revenue codes 027x with NRS was billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare Rules. Based on this information we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the claim was billed with a HIPPS code with a 5th position S and did not also report a non-routine supply revenue with covered charges.Therefore, we decided that the Plan does not have to pay for home health services provided on April 22, 2018 through April 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased on February 27, 2020.
You asked the Plan to pay for the eyeglasses. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Medicare does not cover eyeglasses unless cataract surgery is done and if the optical supplemental provider does not pay then you are responsible.
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. We looked at the file and the Plan's rules. The supplemental optical provider states they have no claim on file for frames or progressive lenses. The Plan does not cover eyeglasses when no cataract surgery has occurred. Therefore, we decided that the Plan does not have to pay for eyeglasses purchased on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided while inpatient.
You asked the Plan to pay for the self-administered drugs. You say that you were unable to self-administer the
drugs because of your condition. The Plan denied your request. The Plan says the self-administered drugs are
not covered under your Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided while inpatient.
Benefits for the self-administered drugs 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CTA scan of the abdomen and pelvis for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the swelling has all resolved after drainage of the lymphocele on December 16, 2019.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the issue in this case is the history of right external iliac vein thrombus and the initiation of anticoagulant therapy. The deep pelvic veins cannot be assessed using ultrasound and while the lower extremities remain asymptomatic it is crucial to document no residual thrombus within the deep pelvic veins since if same are present anticoagulation must continue. Note the deep pelvic veins are dangerous origins of devastating pulmonary emboli and need to be ruled out prior to discontinuing anticoagulation.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 scan have been met.Therefore, we decided that the Plan has to pre-approve CTA scan of the abdomen and pelvis for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 9, 2020.You asked the Plan to pay for the extraction. You say that the documentation given to you by the Plan did not specifically say that prior authorization was needed for comprehensive dental services.The Plan denied your request. The Plan says that you have a deductible that needs to be met before payment can be made.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 responsible for a50% coinsurance of the covered plan allowance after the $100 annual deductible is met. The record shows that you did not meet your $100 deductible prior to this service being rendered. Thus, you are responsible for the allowed amount of $92.50 for the extraction.Therefore, we decided that the Plan does not have to pay for the extraction provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 additional chiropractic visits.You asked the Plan to pre-approve8 additional chiropractic visits. You say that additional chiropractic care is medically necessary for your condition.The Plan denied your request. The Plan says you do not meet criteria for coverage of additional chiropractic services.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 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 eight chiropractic visits. Our reviewer says that the requested chiropractic services are not medically necessary. Our physician reviewer found the chiropractic treatment requested is neither supported nor allowed per Medicare guidelines as there is no evidence demonstrated of a subluxation of the spine. Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment become supportive rather than corrective in nature, the treatmentis then considered maintenance therapy. The services requested in this case are maintenance therapy, which is not a covered benefit by Medicare.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 chiropractic visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 additional chiropractic visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 85060 provided on November 23, 2019.You asked the Plan to pay forCPT code 85060. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of CPT code 85060 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 85060 provided on November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on April 6, 2020.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 outpatient services provided on April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for special gingival irrigation (D4921 x 4) provided to the enrollee on February 17, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in the enrollee's EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for special gingival irrigation (D4921 x 4) provided to the enrollee on February 17, 2020 by an out-of-network provider.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for fungemia. The enrollee is to receive a prolonged course of antifungal medication. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 pay for the injection of sclerosant (36471) provided on December
11, 2019.
You asked the Plan to pay for the injection of sclerosant. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says Medicare rules for payment have not been
met because CPT code 36471 exceeds the allowable units of service of 1 for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 36471 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the injection of sclerosant have not been met.
Therefore, we decided that the Plan does not have to pay for the injection of sclerosant (36471) provided on
December 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON psychotherapy. You say that the enrollee's care facility requested this service. The Plan denied your request. The Plan says this service was not authorized.
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 has network providers available who can provide 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 psychotherapy provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One (J7325).
You asked the Plan to pre-approve the Synvisc One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Synvisc One. Our reviewer says that the member has not tried and failed Orthovisc and Monovisc. Our physician reviewer found the documentation does not support that Monovisc and Orthovisc would likely be less effective. 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 Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One (J7325).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 31, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records to prove
medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not include a valid physician order, lab requisition, or
medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve an evaluation. We decided that the Plan does not have to pre-approve six office visits.
You asked the Plan to pre-approve an evaluation and six office visits to be provided by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
We decided that the Plan has to pre-approve an evaluation. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pre-approve an evaluation. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found the supplied documentation supports that the referral to oral medicine or oral surgery is based on a persistent pain condition most likely medical in nature. The possible dental sources have been eliminated by evaluation and treatment by an endodontist and an evaluation for non-dental source pain, though presenting in the mouth, is indicated. The consultation is considered medically necessary due to continued symptoms of short, electric type pain.
Therefore, we decided that the Plan has to pre-approve an evaluation.
We also decided that the Plan does not have to pre-approve six office visits. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no specifics provided as to the actual treatment or evaluations rendered at any visit due to a lack of records. There is also no claim form provided to indicate what procedures were performed. Therefore, the six visits cannot be considered medically necessary due to a lack of documentation.
Therefore, we decided that the Plan does not have to pre-approve six office visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.