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

We decided that the Plan does not have to pre-approvethe complete upper and lower denture.You asked the Plan to pre-approvethe complete upper and lower denture. You say that the dentures did not fit right. You say that you need a new set.The Plan denied your request. The Plan says these are only covered one procedure every 5 years.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 also has a maximum benefit of one complete upper and lower denture every 5 years. The records show that the plan paid fora complete upper and lower denture on November 19, 2018, which exhausted the benefit.Therefore, we decided that the Plan does not have to pre-approvethe complete upper and lower denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on July 22, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.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 Planto pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided on July 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Genvisc 850 25mg/2.5 ml syringe for the enrollee.You asked the Planto pre-approvethe syringe. You say that this is medically necessary.The Plandenied your request. The Plansays[Enter plan denial rationale, e.g. "...rules for SNF care have not been 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 the syringe. Our reviewer says that the requested drug is not medically reasonable or necessary.Our physician reviewer found the review has determined that The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation indicates that the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 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 syringe have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Genvisc 850 25mg/2.5 ml syringe for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Intracept Procedure.You asked the Plan to pre-approvean Intracept Intraosseous Nerve Ablation System. You say that the enrollee has ongoing pain and the only other option is an invasive surgical procedure.The Plan denied your request. The Plan says there have been no specific studies done to identify that this procedure is appropriate for back pain.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 an Intracept Intraosseous Nerve Ablation System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/ investigational procedure at this point in time. Long term efficacy and safety have NOT been proven. The request is therefore, not considered 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 an Intracept Intraosseous Nerve Ablation System have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Intracept Procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee is able to tolerate IRF rehab.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 9, 2020 with epithelioid neoplasm of lumbar spine. He needs contact guard assist with functional ambulation. His pain is controlled. He has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forlab services provided to the enrollee on October 2, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatphysicians may be not bill or be separately paid for the technical and/or professional components of laboratory services performed in a facility setting.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Our doctor found that the documentation shows the provider's interpretation of pathology testing. The health plan has not provided documentation of global billing on the part of the facility, or proof that the provider is on staff at the facility. Providers who are not on staff at a facility, can bill for their professional services separately, while the facility should bill for the technical component of the services. The health plan has not fully supported their argument, while the appellant has provided proof of the provision of the billed professional services.Therefore, we decided that the Planhas to pay forlab services provided to the enrollee on October 2, 2019.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 to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered to the enrollee on April 27, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from April 25, 2019 to July 25, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period isnot covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level ofcare and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 15, 2019 to April 24, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. Theenrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from April 25, 2019 to July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.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 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 forphysician services provided on October 25, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Hymovis.You asked the Plan to pre-approveHymovis. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for Hymovis is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Hymovis.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 Hymovis. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Hymovis. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not indicate that Orthovisc and Monovisc wouldlikely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Hymovis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on May 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered to the enrollee on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services rendered to you from July 25, 2019 to October 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider is not Medicare-certified.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe chiropractic services rendered to you from July 25, 2019 to October 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forpulmonary stress testing (94618) provided on August 15, 2019.You asked the Plan to pay forpulmonary stress testing. You say that this should be reprocessed.The Plan denied your request. The Plan says the documentation was insufficient to support this code.The Plan must follow Medicarerules. 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 94618 is pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed.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 pulmonary stress testing. Our reviewer says that the billing of CPT 94618 is not supported. Our physician reviewer found the provided medical records indicate that the enrollee underwent pulmonary function testing, not pulmonary stress testing, on the date of service in question.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pulmonary stress testing have not been met.Therefore, we decided that the Plan does not have to pay forpulmonary stress testing (94618) provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe comprehensive eye exam provided on October 23, 2019.You asked thePlan to pay forthe eye exam. You say that you feel that this should be covered since you needed to be evaluated due to eye pain.The Plan denied your request. The Plan says that your plan only covers one comprehensive exam per year so this is not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were provided with the eye exam by  a contract provider. The file does not show that the plan provided notice that the eye exam would not be covered. Under Medicare rules, this means the eye exam is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe comprehensive eye exam provided on October 23, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you need rehab.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 requestto pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you presented to the hospital on March 18, 2020 with leg weakness and atypical pain. You need some assistance withbed mobility, transfers, and walking 50 feet. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may benefit from further therapy, you do not require an intensive therapy program in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe wig purchased on August 6, 2019.You asked the Plan to reimburse you forthe wig. You say that because of a medical condition you need a wig.The Plan denied your request. The Plan says Medicare does not cover wigs and your contract does not include enhanced benefits that would cover wigs.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say that a cranial prosthesis is statutorily excluded.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to reimburse you forthe wig purchased on August 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee cannot be adequately care for in her current condition at a lower level of care.The Plan denied your request. The Plan says the enrollee's current needs are being met in the acutesetting.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 physician reviewer found that the enrollee was admitted to an acute hospital with a small bowel obstruction. She is on total parenteral nutrition, has an abdominal drain tube in place, and has a wound vacuum device. The acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health planWe 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on September 25, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0648). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. Thismeans that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on September 25, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pay forradiology services received on October 8, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatthe billed service was denied, because it was reported as a screening study for a female.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. the plan follows these rules.These services were provided by a contract provider. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan.Therefore, we decided that the Planhas to pay forradiology services received on October 8, 2019.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 to open the case again, we will send you a letter.