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

We decided that the Plan does not have to pay for the self-administered drugs provided on February 18, 2021, and February 19, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were not self-administered by you but were administered by medical staff. The Plan denied your request. The Plan says self-administered drugs are not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for the self-administered drugs provided on February 18, 2021, and February 19, 2021.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the injection services for March 19, 2020.
You asked the Plan to reduce the cost share for the services provided. You say that your copay should be $33.21. The Plan denied your request. The Plan says this claim was processed 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 20% coinsurance for Medicare Part B prescription drugs. The file shows that you received Vedolizumab infusion services (J3380 and 96365). You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare Part B prescription drugs 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 reduce the cost share for the injection services for March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on February 16, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation, and an intraoral periapical radiographic image. You say that you want the Plan to pay. The Plan denied your request. The Plan says the limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every Plan year. The claim for an intraoral periapical radiographic image was 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 limited oral evaluation, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for the limited oral evaluation on February 11, 2021. Additionally, the allowed amount of the intraoral periapical radiographic image for an out-of-network provider was 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 limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on February 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Eylea.

You asked the Plan to pre-approve Eylea. You say that the enrollee needs this injection due to her condition. The Plan denied your request. The Plan says the denial of authorization for Eylea is correct, because the Plan requires a trial of Avastin, Mvasi, or Zirabev before it will approve Eylea.

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 Eylea. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Eylea. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Avastin, Mvasi, or Zirabev. The
documentation does not show that these drugs would likely be less effective and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve use of Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that acute inpatient hospital care will be medically necessary following the enrollee's surgery. The Plan denied your request. The Plan says this inpatient care is not medically necessary.
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 payment are met in this case. Our physician reviewer found The review indicates that the enrollee is undergoing a planned elective reverse total shoulder arthroplasty. The enrollee is medically stable and will be provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT codes 23472 and 20610 are not listed on the CMS Inpatient Only List. The procedures are currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 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 acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair upgraded electronics. 
 
You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair 
expandable controller harness (E2313), power wheelchair electronic connection (E2311). You say that you 
need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says you do not 
require an expandable controller because you are noted to have functional upper extremity strength and can 
control the power options with their own switches. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked the file and Medicare rules. The record shows upper limb strength and function are adequate for you 
to control the power options using their own switches which are included in the allowance of the power 
options. Based on this information, we decided that Medicare rules for coverage of power wheelchair 
expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair 
electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-
approve Group 3 power wheelchair upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on April 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 had network providers available who could have provided 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 the subsequent nursing facility care (99309) provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 is 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. Based on
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on August 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on 
March 19, 2021. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you were told that 
you would not owe a copayment. 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 $40 
copayment for outpatient surgery when conducted by a specialist.  
 
You received a fine needle aspiration biopsy on March 19, 2021. A fine needle aspiration biopsy is considered 
an outpatient surgical procedure. Therefore, you are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for a fine needle aspiration biopsy. A fine needle aspiration 
biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 a fine 
needle aspiration biopsy provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) provided on August 24, 2020.
You asked the Plan to pay for the RFA. The Plan denied your request. The Plan says this is an experimental procedure.
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 pay for the RFA. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The requested genicular nerve radiofrequency ablation of the left knee 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 the RFA have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) provided on August 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture.
You asked the Plan to pre-approve the lower partial denture. You say that you had your teeth removed and need bottom dentures. The Plan denied your request. The Plan says there is more than 50% bone loss, active periodontal disease and the medical necessity for the lower partial denture is not established.
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. The Plan covers the lower partial denture when the services are medically necessary and reasonable.
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 lower partial denture. Our reviewer says that the criteria for coverage for a removable partial has not been met. Our physician reviewer found that the periodontal condition of the remaining mandibular teeth is poor and should be treated prior to placement of a partial denture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the lower partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve the lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a leiomyosarcoma
specialist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary as there is appropriate care available in-plan.
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
an out-of-network referral to a leiomyosarcoma specialist
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5920) and an acrylic socket
(L5631).

You asked the Plan to pre-approve an alignable system and an acrylic socket. You say that the requested items
are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been
met because the requested items are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that the item coded L5631 is not reasonable and necessary as an
addition to an above knee preparatory prosthesis coded L5590.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an alignable system. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that the preparatory prosthesis approved by the Plan has a non-alignable system; therefore, the
requested alignable system is not appropriate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an alignable system have not been met. An acrylic socket is not reasonable and
necessary in this case. Therefore, we decided that the Plan does not have to pre-approve an alignable system
(L5920) and an acrylic socket (L5631).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from October 12,
2020, through December 7, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you submitted your statement of
the charges for review and are appealing this account. The Plan denied your request. The Plan says the
copayments 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 each Medicare-covered physical therapy and speech-language therapy visit.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $760 ($40/visit x 19 visits = $760). Physical therapy falls within the "Outpatient Rehabilitation 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 physical therapy provided from October 12, 2020, through December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 2, 2020.

You asked the Plan to pay for the orthosis. You say that the plan failed to timely pay. The Plan denied your request. The Plan says the reasonableness of the equipment was not established.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension
sleeve provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 4, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you received ultrasounds and during this visit the provider told you everything looked good and that was it. 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 $100 copayment for radiological diagnostic services. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on March 4, 2021.