Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Prolia
You asked the Plan to pre-approve these services. You say that the enrollee has GERD, a contraindication for oral bisphosphonates. The Plan denied your request. The Plan says that 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 medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. It is noted that she has a history of gastroesophageal reflux disease (GERD) and stage three chronic kidney disease (CKD). The enrollee has suffered an ankle fracture in a fall, and two rib fractures in two separate falls. She has not tried and failed the plan's required drugs of oral bisphosphonates and zoledronic acid. The enrollee's rheumatology provider documents that an oral bisphosphonate and zoledronic acid would be more likely to have adverse effects for the enrollee, given her history of GERD and CKD; therefore, Prolia is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve Prolia
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network radiation treatments.
You asked the Plan to pre-approve the out-of-network services. You say that you have limited support for transportation. The Plan denied your request. The Plan says your plan covers providers outside of your network only when your medical needs cannot be met in your network.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The requested provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the requested services. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve out-of-network radiation treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services (CPT 99291) provided to the enrollee from July 17, 2019 to July 19, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 -25 (1 Unit) remains not supported.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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records submitted for July 18, 2019does not include documentation of time spent providing critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, therefore, the service cannot be verified. The medical records submitted for July 19,2019 does not include documentation of time spent providing critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, therefore, the service cannot be verified.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 services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services (CPT 99291) provided to the enrollee from July 17, 2019 to July 19, 2019.
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 benefit from short-term rehabilitation.
The Plan denied your request. The Plan says that you do not require skilled daily therapy or nursing in an
inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on March 29, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the place of service must reflect the location of the enrollee when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We looked at the file and the rules. The claim provided shows a place of service code as 81. There is no indication that the specimen was taken at the independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay forthe lab services provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the services. You say that you want reprocessing for payment. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 office visit services provided to the enrollee on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint injections.You asked the Plan to pre-approvethe requested services. You say that the enrollee is unable to stand or sit in the same position due to intractable lumbar pain.The Plan denied your request. The Plan says the enrollee did not experience at least 80% relief of pain, or at least 50% improvement in previously painful movements.The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She has had trials of physical therapy, medication trials, and still has pain with a radicular component. She had a diagnostic medial branch block on March 16, 2019, which was negative. She also has an L1 vertebral fracture. It is medically unreasonable to repeat a negative test. Therefore, the requested procedure is 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approvefacet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 28, 2019.You asked the Plan to waive the copayment for the office visit. You say that he didn't do anything for you. You say that you want this bill to go away.The Plan denied your request. The Plan says the copayment applied correctly.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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for a urinary tract infection. 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 office visit provided on October 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 26, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider must give a specific reason for doing a definitive drug test.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the provider must give a specific reason for doing a definitive drug test.
There should be documentation that there is concern about misuse of medications. No clinic notes were sent for review. The review indicates that the requested services were not 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 26, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe skin biopsy or the lesion removal procedure provided on September 26, 2019 and October 31, 2019.You asked the Plan to waive the copayments forthe skin biopsy and the lesion removal procedure. You say that you do not understand why you have a copayment from the specialist and the facility. You say you are being double billed. 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 $50 copayment for each specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the skin biopsy and a $50 copayment for the lesion removal procedure. The skin biopsy and the lesion removal procedure fall within the "Outpatient hospital services" benefit category. The record shows you were billed separately by the facility and the physicians. 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 doesnot have to waive the copayments forthe skin biopsy or the lesion removal procedure provided on September 26, 2019 and October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on September 16, 2019 to September 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that you depend upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the member's insurance. Your provider gave medically necessary services to the member in good faith. In consideration for the services rendered, the doctor is seeking reimbursement from the Plan. The Plan denied your request. The Plan says the physician and rendering facility are non-participating providers. The plan did not authorize any services for the facility or physician. There is no referring provider on file. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature. After the appeals department reviewed all the available documentation, the Plan made the final determination to uphold the original denial since prior authorization was not obtained as required under the plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's EOC.
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 subsequent nursing facility care (99308) provided on September 16, 2019 to September 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) provided by the physician from September 20, 2019 to October 10, 2019.
You asked the Plan to pay for the extra-spinal chiropractic manipulative treatment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit by Medicare or the health plan.
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 provided do not meet Medicare criteria for coverage of chiropractic services and therefore, are not covered under the Plan contract. Therefore, we decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) provided September 20, 2019 to October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ottobock C-brace, lower extremity orthoses (L2999).
You asked the Plan to pre-approve lower extremity orthoses (L2999). You say that the available research has been promising regarding the Ottobock C-Brace compared to other orthoses. You request reversal of the previous determination and approval of coverage. The Plan denied your request. The Plan says the information provided does not show that this is 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 lower extremity orthoses (L2999). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The records do not support the use of the C brace. More information is needed. There is no recent physical exam documented. Criteria for the brace not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower extremity orthoses (L2999) have not been met. Therefore, we decided that the Plan does not have to pre-approve Ottobock C-brace, lower extremity orthoses (L2999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR).You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that TAVR is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a bicuspid aortic valve with moderate stenosis and a 5.0-5.2 centimeter ascending aortic aneurysm. In this setting, a TAVR is not indicated, since bicuspid valves were excluded from TAVR trials and since TAVR alone would not treat the more pressing problem of the large ascending aortic aneurysm. The TAVR 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 a transcatheter aortic valve replacement (TAVR)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiographic recording (93224) provided on August 27, 2019 by Cardiology Clinic of El Campo.
You asked the Plan to pay for the electrocardiogram. You say that services were medically necessary. The Plan denied your request. The Plan says the services were out-of-network and were not emergent or preauthorized.
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 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 the electrocardiographic recording (93224) provided on August 27, 2019 by Cardiology Clinic of El Campo.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection provided on June 18, 2019.
You asked the Plan to waive the copayment for the epidural injection. You say that you were not aware that changing plans would cause you to have a higher copayment. You say that you have always paid less for this service. The Plan denied your request. The Plan says the copayment applied correctly.
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 $600 copayment per visit for in-network outpatient surgery. You have been asked to pay a $600 copayment for the epidural injection. The epidural injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 epidural injection provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided from June 7, 2019 to September 27, 2019.
You asked the Plan to pay for infrared therapy. You say that this should have been covered. The Plan denied your request. The Plan says this service is not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say that he use of infrared is non-covered for the treatment. We looked at the file and Medicare rules. The service at issue is infrared therapy, which is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided from June 7, 2019 to September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite for 1 surface (D2391) and the resin based composites for 2 surfaces (D2392 x 2) provided on October 16, 2019.

You asked the Plan to pay for the dental services. You say that you needed the dental services. You say that the Plan should pay for. You also say that if you do not take care of your teeth now, then it might cost more for treatment in the future. The Plan denied your request. The Plan says the annual maximum benefit for dental services has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are a covered service, the annual maximum benefit for dental services has been exceeded. The record shows that the Plan paid $370.50 for dental services you received on May 13, 2019 and $49.50 for dental services that you received on October 7, 2019. Therefore, we decided that the Plan does not have to pay for the resin based composite for 1 surface (D2391) and the resin based composites for 2 surfaces (D2392 x 2) provided on October 16, 2019.