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

We decided that the Plan does not have to pre-approveGelsyn-3 (J7328).

You asked the Plan to pre-approveGelsyn-3. You say that Gelsyn-3 is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically necessary. Our physician reviewer found the documentation does not show a trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met.Therefore, we
decided that the Plan does not have to pre-approveGelsyn-3 (J7328).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveArmodafinil 150mg Tablets.You asked the Plan to pre-approveArmodafinil. You say that Armodafinilis medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.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-approveArmodafinil 150mg Tablets.Benefits for Armodafinilmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2020, by
an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on September 30,
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hospital for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says out-of-network providers are not covered.
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
a referral to an out-of-network hospital for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ECG/monitoring and analysis (93271) provided on September 22, 2019.You asked the Plan to pay forthe ECG/monitoring and analysis (93271). You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the corrected claim was not filed timely per Medicare guidelines.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record showsthat a corrected claim for the ECG/monitoring and analysis (93271) was not filed until October 26, 2020. This means that more than one calendar year from the date of service had passed before a corrected claim was filed.Therefore, we decided that the Plan does not have to pay forthe ECG/monitoring and analysis (93271) provided on September 22, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 4, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration because the member is in a nursing facility and does not have control over what lab is used.The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.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 forthe medical services provided on September 4, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvea skin graft with Kerecis Omega3 for the enrollee.You asked the Planto pre-approvethe skin graft. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe medical criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 skin graft. Our reviewer says that the requested skin graft is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a non-healing chronic wound with fat layer exposed that failed all first line treatments and therefore meets criteria for the standard of care with a skin graft with Kerecis Omega3.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 skin graft have been met.Therefore, we decided that the Planhas to pre-approvea skin graft with Kerecis Omega3 for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued allergy shots to be provided out of area (OOA).You asked the Planto pre-approvethe OOA allergy shots. You say that your allergist says that this is medically necessary so you feel that it should be covered out of network.The Plandenied your request. The Plansaysthese services do not meet the criteria for out of network coverage.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. Urgently needed OOA services means services required due to an unforeseen flare up in a known condition.In this case, the need for these services is not unforeseen. As such, they do not meet the definition of urgentlyneeded OOA care. Therefore, we decided that the Plandoes not haveto pre-approvecontinued allergy shots to be provided out of area (OOA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveHydrocodone-Acetaminophen for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare says Part B programs can only provide limited benefits for prescription drugs.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 Plandoes not haveto pre-approveHydrocodone-Acetaminophen for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe mammography services (77063 and 77067). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services were not urgent, emergent orapproved in advance.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 theitem/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 forthe medical services provided on November 3, 2020 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services provided on August 18, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that you feel you shouldnot be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received laboratory services 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 $20 copayment per visit for laboratorytests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on August 18, 2020. You have been asked to pay an $11.46 copayment for the laboratory services, which is less than the contracted $20 copayment amount. The laboratory services fall 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 forthe laboratory services provided on August 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization is required to receive care from out-of-network providers unless the services are considered urgent or emergent.
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 physician's services provided on October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 30,
2020.
You asked the Plan to waive the copayment for the CT scan. You say that you feel you should not be
responsible for this cost share amount and 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 $200
copayment for advanced imaging services (such as CT scans and MRIs).
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT scan on
September 30, 2020. You have been asked to pay a $200 copayment for the CT scan. 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 CT scan
provided on September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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-approvea Vertiflex Superion spacer
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature. The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup. You say that you would like to appeal the complete crown procedure.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora portable oxygen concentrator purchased on May 4, 2020.You asked the Planto pay forthe concentrator. You say that this was paid for in 2017 andis needed for travel.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules say that only rented oxygen equipment is eligible for coverage.The item at issue in this appeal is for use outside of the home andwas bought rather than rented. Although this item may be helpful, neither Medicare nor the Plan covers purchased equipment for use outside the home.Therefore, we decided that the Plandoes not haveto pay fora portable oxygen concentrator purchased on May 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency services (CPT 93010 and CPT 36556) provided to the enrollee on August 12, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the procedure code is inconsistent with the modifier used and the procedure code is incidental to a primary procedure.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 definitionof the denied codes is:CPT 93010:Electrocardiogram, routine ECG with at least 12 leads; interpretation and report onlyCPT 36556:Insertion of non-tunneled centrally inserted central venous catheterWe 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 supported by the medical records. Our coding reviewer found CPT 93010 is bundled with CPT 36556 which was performed on the same date of service by the same physician/practice.  NCCI Edits do allow for a modifier to unbundle these services providing the medical records include documentation to validate that these two services are not related.  A modifier was not used when CPT 93010 was billed along with CPT 36556, therefore it cannot be considered for reimbursement. CPT 36556 was submitted to the health plan with an appended 50 modifier. This code has a bilateral indicator of "0" which means "adjustments for bilateral procedures does not apply.  Since the "50" modifier is not appropriate to append to CPT 36556, this code was submitted incorrectly and is not eligible for reimbursement based on the wayit was billed.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 foremergency services (CPT 93010 and CPT 36556) provided to the enrollee on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveknee orthosis (L1851).You asked the Plan to pre-approvethe orthosis. You say that you are requesting reconsideration as this brace will increase the enrollee's ability to perform ADL's and stabilize an unstable left knee.The Plan denied your request. The Plan says the request is not medically necessary because the records do not show that the enrollee have objective evidence of instability.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of knee instability by examination of the enrollee with objective description of joint laxity. Claims will be denied if only pain or a subjective description of joint instability is documented.
We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approveknee orthosis (L1851).