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

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on October 21, 2019.You asked the Plan to pay for the periodic oral evaluation and bitewings. You say that according to your 2019 EOC, you should have a zero copay for exams and x-rays.The Plan denied your request. The Plan says these services were provided by an out-of-network provider. The Plan also says that the cost share was applied correctly per your plan 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 contract clearly says that you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on October 21, 2019.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility (SNF) level.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on July 9, 2019.You asked the Plan to waive the copayment for the MRI. You say that the MRI was performed at a free-standing facility. You say that the copayment should be less.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for advanced imaging services at an in-network outpatient hospital. You have been asked to pay a $250 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the MRI was billed by the hospital. 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 MRI provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea power mobility device (PMD).You asked the Plan to providea power wheelchair. You say that you are unable to complete your ADLs with a walker because of pain, neuropathy, and poor balance.The Plan denied your request. The Plan says you do not meet criteria for a power wheelchair.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 provide a power wheelchair. Our reviewer says that the medical records indicate you havechronic joint pains and impaired mobility. You havelimited mobility, and ambulateshort distances with a walker.An occupational therapy note indicates there is insufficient space in the home,for power mobility device use. Our physician reviewer found in this case, you arenot noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker).  The documentation does not supportthat the requested PMD is necessary and reasonable to meet the enrollee's needs and improve and maintain the enrollee's overall health status. Therefore, this request is not medically necessary for a PMD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met.Therefore, we decided that the Plan does not have to providea power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share forthe radiation treatments or the specialist office visit provided from September 3, 2019 to September 23, 2019.You asked the Plan to reduce the cost share forthe radiation treatments and the specialist visit. You say that you were told that the providers were in-network.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay50% coinsurance for out-of-network therapeutic radiology and a $55 copayment for out-of-network physician specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a total of $944.09 for the radiation treatments and the specialist visit. The radiation treatments fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The specialist visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network. 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 reduce the cost share forthe radiation treatments or thespecialist office visit provided from September 3, 2019 to September 23, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Sodium 1% gel.
You asked the Plan to pre-approve Diclofenac Sodium 1% gel. You say that the medication is necessary. The
Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D
prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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-approve Diclofenac Sodium 1% gel.
Benefits for Diclofenac Sodium 1% gel may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACH is a better choice for some patients.The Plan denied your request. The Plan says the enrollee does not need LTACH care since she can be managed in the nursing facility that cared for her prior to this admission.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 the review indicates that the request for admission to a LTACH is not medically necessary and reasonable. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four testing (95999) provided on February 14, 2019 by physician.You asked the Plan to pay for the Train of Four testing. You say that the services were medically necessary.The Plan denied your request. The Plan says payment for Train of Four testing is bundled in the Neuromonitoring services already approved.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, we have confirmed that code the Train of Four testing has a bundled relationship with code 95908 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for Train of Four testing (95999) provided on February 14, 2019 by physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pain management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON pain management care. You say that you want the Plan to pay for you to see this provider since they are the only one who has been willing to give you the medication you need. You do not wish to try any other treatment other than this medication and should be allowed to see the one provider who will prescribe it. The Plan denied your request. The Plan says there are numerous pain management providers in the network who can assume your pain medicine needs. The requested provider does not accept insurance.
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 the pain management services to be provided by an out of network (OON) provider.
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 it is felt that the enrollee would benefit from intensive inpatient rehab.The Plan denied your request. The Plan says the enrollee is medically stable and does not require acute inpatient hospital care for her condition.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee recently suffered a peri-prosthetic femur fracture and underwent surgical repair on 2/23. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose CT (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the LDCT scan. You say that the enrollee needs another screening due to his diagnosis of pneumonia and immune suppression. The Plan denied your request. The Plan says this was provided once this year and cannot be approved again within one year. A diagnostic CT scan of the chest could be approved if requested.
The Plan must follow Medicare rules. Medicare rules say that LDCT for lung cancer screening is covered once per year. In this case, the enrollee has had an LDCT for screening in the past year. A repeat test is not covered. Therefore, we decided that the Plan does not have to pre-approve a low-dose CT (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special periodontal surgery coded as D4277 and D4278 on May 9, 2019.You asked the Plan to pay forthe dental services. You say that you did make a phone call and they said only scaling was covered. The 2019 book on page 9 says oral surgery is somewhat covered.The Plan denied your request. The Plan saysthis service is not covered under the plan benefits.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. Services not listed under the Description of Benefits is not covered by the plan.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 forthe special periodontal surgery coded as D4277 and D4278 on May 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the LTACH servicesarenot medically necessary.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 that there are no current long-term acute care needs documented in the member's clinical notes. The enrollee requires continued acute level of care hospital services and is receiving appropriate care at the present acute care hospital.The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not availableat the health care setting being offered by the health plan.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram interpretation and report (93010) provided October 12, 2019.
You asked the Plan to pay for an electrocardiogram interpretation and report. You say that the services should be separately paid. The Plan denied your request. The Plan says the interpretation and report are not authenticated by the rendering physician.
The Plan must follow Medicare rules. The rules say that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram interpretation and report have not been met. In this case, the electrocardiogram report is not signed by the physician responsible for the enrollee's care. Therefore, we decided that the Plan does not have to pay for an electrocardiogram interpretation and report (93010) provided October 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foran ultrasound screening for abdominal aortic aneurysms (76706) provided on October 4, 2019.You asked the Planto pay foran ultrasound screening for abdominal aortic aneurysms. You say that you never received this service previously.The Plandenied your request. The Plansaysthatyou received this service in 2017 already and it is only covered once per lifetime.The Plan must follow Medicare rules. The rules state that an ultrasound screening for abdominal aortic aneurysms is covered once per lifetime.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound screening for abdominal aortic aneurysms have been met.The record shows that you previously received anabdominalultrasound(76700), but it was not a screeningcode(76706) and was not done for screening purposes (it was done for abdominal pain).The record does not show that you previously exhausted the benefit for this screening service.Therefore, we decided that the Planhas to pay foran ultrasound screening for abdominal aortic aneurysms (76706) provided on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3.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 coverage criteria has not been met. Our physician reviewer found the records do not show a trial of the plan preferred drugs or any reason why they would be unsafe or ineffective for this 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 Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One for intra-articular injection (code J7326).
You asked the Plan to pre-approve the Gel-One. You say that the clinical documentation provided proves medical necessity. The Plan denied your request. The Plan says Gel-One is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy is covered for certain medical indications. 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 Gel-One. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found this injured worker presents with a history of right knee pain. Functional limitations are noted in activities of daily living. Clinical exam findings have documented lateral joint line tenderness, trace effusion, and limited range of motion generally consistent with imaging evidence of a complex tear to the posterior horn of the lateral meniscus and lateral compartment chondromalacia. Reported x-ray findings show relatively well-preserved medial and lateral joint spaces. The enrollee is status post right knee partial lateral meniscectomy on August 17, 2019 with a reported onset of right knee pain with prolonged driving on September 15, 2019. He has reportedly failed activity modification, NSAIDs, heat/ice, and physical therapy. It is noted that he had failed to improve with previous corticosteroid injection, but the date of this injection is not documented. Additionally, the enrollee underwent a lumbar epidural steroid injection with 90% short term improvement. There is no clear radiologic evidence of significant osteoarthritis of the knee.