Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 6 additional physical therapy visits.

You asked the Plan to provide 12 additional physical therapy visits. You say that you need additional physical therapy due to your worsening medical condition. The Plan denied your request. The Plan says only 6 PT visits are approved to allow for transition to a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 6 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 

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 remaining requested 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide 6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the scooter accessories provided on January 2, 2021 to January 4, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that you were told you had to buy the items first and then you would be reimbursed. The Plan denied your request. The Plan says the services were not authorized.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the scooter accessories provided on January 2, 2021 to January 4, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.

You asked the Plan to pre-approve facet blocks. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary when specific criteria are met. 

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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found the operative report does not correspond to the diagnosis at all. If only 50% improvement was obtained, then the block should be interpreted as negative, and another pain generator should be sort. The request is not 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 facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the Vertiflex procedure are not met because the requested service is experimental/investigational.

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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain retainer crowns (D6740 x 2), and the porcelain
pontic (D6245) provided on October 19, 2020.

You asked the Plan to pay for the dental services. You say that you thought that the services were covered
under your Dental Plan because you went to a contracted dental provider. You say that you were receiving a
filling for 1 tooth not 3. You say that if you had known that you had to pay for the services out of pocket, you
would not have had them done. You also say that you are upset about the lack of communication between the
provide, plan, and yourself. The Plan denied your request. The Plan says the porcelain retainer crowns are not
listed as covered services. The Plan says that porcelain pontic is not listed as a covered service either.

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 bridges are listed as covered, the
Evidence of Coverage states that covered dental services are subject to the Dental Plan's Processing Policies,
limitation and exclusions. The record shows that porcelain retainer crowns and pontics are not listed as covered
services. Therefore, we decided that the Plan does not have to pay for the porcelain retainer crowns (D6740 x
2), and the porcelain pontic (D6245) provided on October 19, 2020.

Your complaint about the lack of communication between the provider, Dental Plan, and you is not a valid
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan.
Medicare does not permit us to make a decision about these types of complaints.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's care can be provided in the current acute care 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 the patient appears to be unstable, requiring additional short-term acute care services which can be safely administered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual (physical) therapy techniques to 1 or more regions each 15 minutes (CPT code 97140) provided on December 10, 2020.

You asked the Plan to pay for the services. You say that the doctor recommended Chiropractic treatments for further rehab and healing of your bones, muscles, continual pain, contractures, and spinal alignment. You state you are disabled, and the chiropractic treatments have helped your pain, and mobility tremendously. The Plan denied your request. The Plan says they must follow Medicare guidelines and Medicare does not cover physiotherapy performed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for manual (physical) therapy techniques to 1 or more regions each 15 minutes (CPT code 97140) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the panoramic x-ray (D0330), and the unspecified preventive service (D1999) provided on December 31, 2020.

You asked the Plan to pay the full amount for the dental services. You say that you live out in the country. You say that this dental office is within a reasonable distance. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network dental services are paid according to a maximum allowable fee schedule and you are responsible for all the fees in excess of this amount from the billed amount. The Plan also says that unspecified preventive service is not listed as a covered service.

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 the services are listed as covered, out of network providers may bill you for any amount greater than the MAC payment made by the plan to the provider.

This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the panoramic x-ray (D0330), and the unspecified preventive service (D1999) provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on December 2, 2020.

You asked the Plan to pay an additional amount for a periodic oral evaluation, teeth cleaning, and an intraoral complete series of radiographic images. You say that you were not aware the provider was out-of-network and you would have to pay more. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 6, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that you were informed this was a routine eye exam and you were covered in full. 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 $40 copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. 

You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was performed. 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 eye exam provided on January 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Fluorouracil (J9190) under the Medicare
Part B benefit.

You asked the Plan to pre-approve Fluorouracil. You say that the requested treatment is necessary care for the
enrollee. The Plan denied your request. The Plan says rules for coverage under the Medicare Part B benefit
have not been met.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, you have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve treatment with Fluorouracil (J9190) under the Medicare Part B benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable oxygen concentrator to be provided by an out-of-network provider.

You asked the Plan to pre-approve the portable oxygen concentrator. You say that you are homebound due to mobility restrictions and you need the portable to be more mobile. The Plan denied your request. The Plan says in-network providers are available.

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 portable oxygen concentrator to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair.

You asked the Plan to pre-approve a wheelchair. You say that the item is 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. Medicare rules say that if an individual is a patient in an institution or distinct part of an institution which provides the services described in the bullets above, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a weight scale and a blood pressure cuff.

You asked the Plan to provide a weight scale and a blood pressure cuff. You say that these items are necessary to monitor weight loss and hypertension. The Plan denied your request. The Plan says blood pressure cuffs are not covered by Medicare or the Plan when not used in the setting of dialysis monitoring. Weight scales are not considered a medical device.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Weight scales are not medical in nature. Therefore, we decided that the Plan does not have to provide a weight scale and a blood pressure cuff.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the indomethacin (A9270) provided on December 8, 2020. We also decided that the Plan does not have to waive the copayment for the insertion of stent into pancreatic or bile duct with flexible endoscope via mouth (43274) provided on December 8, 2020.

You asked the Plan to pay for the self-administered drug and waive the copayment for the outpatient surgery. You say that these services should be covered by your insurance. The Plan denied your request. The Plan says indomethacin is considered a self-administered drug.

The Plan says that self-administered drugs are not covered under Medicare Part B. The Plan also says that there is a $300 copayment for outpatient hospital services.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The rules also 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 $300 copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers. 

The self-administered drug that you received is not among the types which are covered by Medicare Part B. Additionally, the Evidence of Coverage clearly states there is a $300 copayment for Medicare-covered surgery or other services. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the indomethacin (A9270) provided on December 8, 2020. We also decided that the Plan does not have to waive the copayment for the insertion of stent into pancreatic or bile duct with flexible endoscope via mouth (43274) provided on December 8, 2020.

Benefits for the self-administered drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve Orthovisc. You say that although the enrollee does not have osteoarthritis,
he is in pain and there are no other procedures that can offer relief. The Plan denied your request. The Plan says
this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that viscosupplementation will not be covered when
the diagnosis is anything other than osteoarthritis.

We looked at the file and Medicare rules. The records show that the enrollee has not been diagnosed with
osteoarthritis. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not
been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on November 18, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you have never had to pay for this before. 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. 

You have been asked to pay a $110 copayment for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/radiological diagnostic 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 an MRI provided by a participating provider on November 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for Synvisc-One 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 Synvisc-One. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the enrollee has pain related to osteoarthritis of both knees. The enrollee has failed conservative treatment and corticosteroid injections. The Plan requires a trial of drugs Orthovisc and Monovisc before they will approve the requested drug Synvisc-One. Based on the medical records provided the enrollee has not tried and failed the required drugs. There is no indication 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).