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

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve the Botox. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says off-label use of this drug for your condition 
is not medically accepted per Medicare rules and is not covered based on the available information. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that your 
condition is not a labeled indication for the use of Botox. Our physician reviewer found the documentation 
does not discuss why off-label use of this drug is necessary or reasonable. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
You asked the Plan to pre-approve the POV. You say that you cannot function on your own and need the scooter to get around. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. You refused to be examined by a licensed physical therapist, which is a requirement before a power operated vehicle can be reviewed for possible approval. Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95910) and needle 
electromyography (97886) provided on July 29, 2019. 
 
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these codes 
are supported in the records. The Plan denied your request. The Plan says there is a more appropriate code for 
the 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 definition of code 95910 is nerve conduction studies; 7-8 studies and 95886 
is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 
 
We find that CPT codes 95910 and 95886 are not supported in the medical record. Specifically, the records do 
not indicate 7-8 nerve conduction studies were performed, therefore 95910 is not supported. Because this is the 
primary procedure, 95886 is also not supported. Based on this information, we decided that Medicare rules for 
coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided 
that the Plan does not have to pay for nerve conduction studies (95910) and needle electromyography (97886) 
provided on July 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on March 19, 
2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that the enrollment guide book for 2020 states 
that minor procedures for emergency treatment of dental pain is a covered benefit, and unlimited per plan year. 
You also say that your dentist believed a root canal was the best treatment for the pain. 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 Plans 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 pay for the 
endodontic therapy (D3330) provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 6, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 for lab work provided on January 6, 2020 by an out of 
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (99239) 
provided on May 3, 2019. 
 
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 
does not support the service billed. 
 
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 medical record. Specifically, the documentation does not 
support that more than 30 minutes of hospital discharge day management services were rendered. 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 hospital discharge day 
management services (99239) provided on May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom breast prosthesis (L8035) and nipple prosthesis (L8033 x 2), for the enrollee.
You asked the Plan to pre-approve the prosthesis. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says they approved 1 unit of L8035 and 2 units of L8033 based on Medicare rules.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis have been met. Review of the records show that the enrollee tried and failed prefabricated prosthesis. The enrollee had a single mastectomy and a result the Plan have approved 1 unit of L8035 and 2 units of L8035. The approval is valid until December 13, 2020. The Medicare rules state, "suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioner that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time." Therefore, we decided that the Plan does not have to pre-approve custom breast prosthesis (L8035) and nipple prosthesis (L8033 x 2), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician 
evaluation.  The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on April 22, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges 
because you were never charged in the past. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $20 
copayment per visit to a specialist.  
 
You have been asked to pay the allowed mount of $10.36, which is less than the $20 copayment for specialist 
services. Specialist services fall within the physician/practitioner services, including doctors office visits 
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 specialist services provided on 
April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 8, 
2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. The Plan denied your request. The Plan says 
your oral exams benefit had been exhausted. 
 
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, oral exams are limited to 1every 6 
months. The record shows that you received a periodic oral evaluation on October 2, 2019 and your oral exams 
benefit was then exhausted for the 6 month time period. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing services (CPT 95397) provided to the enrollee on March 6, 2020.
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 denied code is not appropriate for this 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 definition of code 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method." 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 supported by the medical records. Our physician reviewer found the service rendered was train of four testing, rather than NMJ testing. CPT code 95937 was not the correct procedure code to be used for this service. Rather, the enrollee underwent train of four testing in the setting of neuromonitoring during an epidural steroid injection for low back pain. This service was provided simultaneously as EMG services. The testing was not otherwise done to evaluate a disorder of the neuromuscular junction. Furthermore, per the CPT Assistant, train of four testing is considered to be part of the EMG procedure. In as much this service was not billed/coded correctly. 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 neuromuscular junction testing services (CPT 95397) provided to the enrollee on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on May 24, 2019 to 
November 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there is no referring provider. The Plan says that the member's primary care physician did not 
refer these services. 
 
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 dermatology services provided on May 24, 2019 
to November 22, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the Euflexxa. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Euflexxa. Our reviewer says that the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Our physician reviewer 
found the documentation does not outline contraindications or reasons these medications were not considered. 
 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee. 
 
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 MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has reported right knee 
pain rated at seven out of 10 on July 27, 2020. Physical findings of the musculoskeletal system were reported 
as normal. No specific examination findings of the right knee were noted. He was diagnosed with primary 
osteoarthritis of the right knee. X-ray of the right knee was noted to have last been completed in 2018. Based 
on the provided documentation, there was no reported trial and failure of conservative treatments or recent x-
ray or findings on examination suggestive of a red flag diagnosis to warrant MRI at this time. Therefore, the 
MRI is 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-approve magnetic resonance imaging (MRI) of the right knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the manipulation of the knee under anesthesia provided on January 14, 2020.
You asked the Plan to waive the deductible for the manipulation of the knee under anesthesia. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the manipulation of the knee under general anesthesia on January 14, 2020. The record shows that you had only paid $96.39 toward the $198 deductible. Therefore, you are responsible to pay the allowed amount of $101.61. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the manipulation of the knee under anesthesia was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the manipulation of the knee under anesthesia provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 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 the medical services provided to the enrollee by an out-of-network provider on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not 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 Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on January 29, 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 cervical epidural steroid injection.
You asked the Plan to pre-approve epidural. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this epidural is only covered three times per three to six months period which you have already received.
The Plan must follow Medicare rules. Medicare rules say that cervical epidural block injections are limited to a total of three in a three to six month period. We looked at the file and Medicare rules. You received previous epidurals on May 19, 2020, May 29, 2020, and June 15, 2020. Therefore, an additional epidural would not be covered by Medicare at this time. Based on this information, we decided that Medicare rules for coverage of epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.