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

We decided that the Plan has to pre-approve Hyaluronan (J7321).
You asked the Plan to pre-approve Hyaluronan. You say that the enrollee has had good results with viscosupplementation injections, the last being September 2020. You also say that you feel it is appropriate and recommend the enrollee proceed with another series of viscosupplementation injections to her left knee. The Plan denied your request. The Plan says that there is no documentation in the available medical record regarding the results/outcome of the prior injections, specifically pain relief if any, improved function, and the reduction in anti-inflammatory and/or analgesic medication use.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyaluronan. Our reviewer says that the documentation does support that Hyaluronan (J7321) is medically reasonable and necessary for the enrollee.
Our physician reviewer found the documentation indicates that the enrollee has a diagnosis of unilateral primary osteoarthritis, left knee. Clinical documentation reports the enrollee has a longstanding history of debilitating osteoarthritis involving her left knee, and the pain is aggravated by activity and is somewhat relieved with rest. Per clinical documentation the member has been treated in the past with non- narcotic analgesics, physical therapy, and cortisone injections with limited success. Our reviewer found that the records received reports the enrollee had good results with the viscosupplementation injections the last September 2020. She has presented having increasing symptoms of pain swelling crepitation involving her left knee. The provider is asking for another series of viscosupplementation injections. The clinical documentation reports the enrollee has tried non-narcotic analgesics, physical therapy, and has had good results with the viscosupplementation injection in September 2020. Our physician reviewer also found that the documentation supports that Hyaluronan (J7321) is safe and effective 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 Hyaluronan have been met. Therefore, we decided that the Plan has to pre-approve Hyaluronan (J7321)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.

You asked the Plan to pre-approve Injectafer. You say that this request is medically necessary. The Plan denied
your request. The Plan says prior authorization criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that
Injectafer is not medically reasonable and necessary. Our physician reviewer found the review indicates that
the enrollee is a 70-year-old female with a history of iron deficiency anemia. The criteria for Injectafer have not
been met. Specifically, according to recent labs her Ferritin levels exceed the criteria requirements. The
documentation does not support that the Injectafer is safe and effective for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission for total knee arthroplasty surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has high blood pressure and other health issues so needs to be monitored. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because this is an ambulatory procedure and there is no expectation that the enrollee will require more than a 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The documentation does not support that the admitting physician reasonably expects that the enrollee's necessary hospital care will span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission for total knee arthroplasty surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 5, 2020.

You asked the Plan to pay for the dental service. You say that you understand that this service is covered once per year. You also say that you cannot afford to pay for this service. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency limit 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 limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the limited oral evaluation that you received on September 30, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for hyperbaric oxygen therapy (CPT 99183) provided to the enrollee from June 25, 2020 to June 26, 2020.
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 99183 (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 99183 is "Physician attendance and supervision of hyperbaric oxygen therapy, per session, is reported for physician attendance of each session of hyperbaric oxygen therapy." 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 therapy. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found the report dated June 25, 2020 has physician verification that the code was performed. The criteria for CPT 99183 is confirmed. 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 therapy have been met. Therefore, we decided that the Plan has to pay for hyperbaric oxygen therapy (CPT 99183) provided to the enrollee from June 25, 2020 to June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on July 28, 2020.

You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that more than 30 minutes of discharge day management services.

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 99239 is hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the record. Specifically, the documentation submitted does not show that more than 30 minutes of hospital discharge day management services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid.

You asked the Plan to pay for the hearing aid. You say that the plan should apply the $1,000 hearing aid allowance toward this claim. The Plan denied your request. The Plan says the hearing aids must be prescribed by a network provider (clinical audiologist).

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from network providers. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pain relief gel (A9900) provided December 20, 2020.
You asked the Plan to pay for the pain relief gel. You say that the items were medically necessary. The Plan denied your request. The Plan says the CPT code billed cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A9900 is not supported in the medical record. Specifically, the CPT code billed has a status indicator of "Y" which means it is not eligible for payment under Part B OPPS. This item must be billed to the Durable Medical Equipment Regional Carrier. Based on this information, we decided that Medicare rules for coverage of the pain relief gel have not been met. Therefore, we decided that the Plan does not have to pay for pain relief gel (A9900) provided December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiopulmonary exercise testing (94621).

You asked the Plan to pre-approve cardiopulmonary exercise testing, including measurements of minute
ventilation, CO2 production, O2 uptake, and electrocardiographic recordings (94621). You say that the enrollee
needs this test. The Plan denied your request. The Plan says cardiopulmonary exercise testing in this setting
compared to standard exercise treadmill testing as well as pulmonary function test has not been established as
standard of care.

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 cardiopulmonary exercise testing,
including measurements of minute ventilation, CO2 production, O2 uptake, and electrocardiographic
recordings (94621). Our reviewer says that the requested services are not considered medically reasonable and
necessary in this case. Our physician reviewer found evaluation with CPET at this time would be premature
and not meet current published guidelines. It is generally recommended to be utilized in patients with
significant unexplained dyspnea without other specific explanations. As such, at this time, it would not be
considered medically necessary and would not meet the applicable CMS Section 1862(a) rule for medical
reasonableness and necessity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of cardiopulmonary exercise testing, including measurements of minute
ventilation, CO2 production, O2 uptake, and electrocardiographic recordings (94621) have not been met.
Therefore, we decided that the Plan does not have to pre-approve cardiopulmonary exercise testing (94621).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services to
fully recover. The Plan denied your request. The Plan says the enrollee's care can be provided in the current
inpatient hospital.

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 there is no documentation provided necessitating admission to a LTACH. 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 the enrollee is currently receiving care. 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 plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310), a core buildup procedure (D2950), partial dentures (D5820), analgesia (D9230), and two extractions (D7210) provided on January 21, 2020 and February 25, 2020.

You asked the Plan to pay for the dental services. You say that you told your provider not to exceed your dental allowance of $1,500. You feel that you were mislead, and are also being charged for ill-fitting dentures. The Plan denied your request. The Plan says they have opened a separate grievance case to address your concerns, but the services provided exceeded the $1,500 annual allowance and therefore cannot be covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services in excess of the Plan's $1,500 annual allowance are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3310), a core buildup procedure (D2950), partial dentures (D5820), analgesia (D9230), and two extractions (D7210) provided on January 21, 2020 and February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the polycarbonate lenses (V2784).
You asked the Plan to pre-approve the polycarbonate lenses. You say that the polycarbonate lenses are required for safety reasons. The Plan denied your request. The Plan says polycarbonate lenses are not covered under your supplemental benefit.
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. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. We looked at the file and the Plan's rules. The Plan contract states that the Plan covers one pair of eyeglasses or contact lenses are covered after each cataract surgery that includes insertion of an intraocular lens. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve the polycarbonate lenses (V2784).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on September 29, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you think this should be fully covered. The Plan denied your request. The Plan says [the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for ambulance services. You have been asked to pay $261.28 which is less than your copayment amount of $275 for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance services 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 ambulance services provided by a participating provider on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted special service coded 99199 and the Iv tubing extension set coded S1015 provided on October 22, 2020.
You asked the Plan to pay for the unlisted special service and the Iv tubing extension set. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99199 and S1015 are not supported in the medical record. Specifically, code S1015 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Code 99199 should not be billed by anesthesia provider. Anesthesia services should be billed with codes 00100 to 01999 when billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of the unlisted special service and the Iv tubing extension set have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted special service coded 99199 and the Iv tubing extension set coded S1015 provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).

You asked the Plan to pre-approve HBO therapy. You say that this is needed to prevent loss of limb. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because HBO therapy is non-covered for the enrollee's condition and the enrollee does not have an indication that is covered.

The Plan follows Medicare rules. Medicare rules state that HBO therapy is only covered for treatment of certain, specified conditions.

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 HBO therapy. Our reviewer says that the enrollee does not meet the Medicare criteria for HBO therapy. Our physician reviewer found the enrollee has peripheral vascular arterial disease with a chronic non-healing foot wound. The enrollee has had previous revascularization attempts. There is no acute arterial insufficiency. Medicare specifically excludes chronic vascular insufficiency. Therefore, the requested HBO therapy cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy or HBOT).