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

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328.

You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the best course of treatment for the enrollee is in LTACH setting due to complex medical needs. The Plan denied your request. The Plan says there is no therapeutic advantage in a transfer to an LTACH.
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 is no documentation provided necessitating admission to the LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where 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 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 the LTACH services.
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 services are medically necessary. The Plan denied your request. The Plan says all the services needed can be provided in the current acute care setting already approved.
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 enrollee appears to be more stable and improving, but still requires additional short-term acute care services that can safely be received in the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the enrollee is more stable and additional weaning is completed. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that the enrollee has had inadequate results with non-pharmacologic treatments, simple analgesic therapy, and intraarticular corticosteroids. The Plan denied your request. The Plan says there is no documentation that shows that the enrollee has tried and failed the preferred drugs, Orthovisc and Monovisc.

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 Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found there is no documentation that was provided which supports that the enrollee has tried and failed the Plan's required drugs, Orthovisc and Monovisc. The reviewer found that the provided documentation documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that Euflexxa 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab (Prolia).
You asked the Plan to pre-approve Prolia. You say that the enrollee has tried Alendronate but was not able to tolerate it. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (Prolia).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.

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 self-administered drugs are not 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 pre-approve Repatha Sureclick.

Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), removal of impacted tooth (D7240), and primary closure of a sinus perforation (D7261), or pay more for the problem focused limited oral evaluation (D0140) and extraction (D7210) provided on September 14, 2020 by an OON provider.
You asked the Plan to pay for the preventive procedure, removal of impacted tooth, and primary closure of a sinus perforation, and pay more for the problem focused limited oral evaluation and extraction. You say that you were unable to be seen by an in-network provider. The Plan denied your request. The Plan says the preventive procedure, removal of impacted tooth, and primary closure of a sinus perforation are not covered services under your dental plan. The Plan also says that these services were rendered by an OON provider, and the total liability amount of $1,466.00 was applied correctly.
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 preventive procedure, removal of impacted tooth, and primary closure of a sinus perforation are not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount because the services were rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), removal of impacted tooth (D7240), and primary closure of a sinus perforation (D7261), or pay more for the problem focused limited oral evaluation (D0140) and extraction (D7210) provided on September 14, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services.

You asked the Plan to waive the copayment for urgently needed services. You say that you were not allowed in due to COVID-19 and were told to go to the emergency room. 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 $65 copayment for urgently needed services.

The medical records show that you received urgently needed services. Therefore, you are responsible to pay the $65 copayment.

You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge.
You asked the Plan to pre-approve pontic - porcelain/ceramic (D6245) tooth 7 and 8 or retainer crown - porcelain/ceramic (D6740) tooth 6 and 9. You say that the enrollee needs a dental bridge. The Plan denied your request. The Plan says the information submitted does not say why a denture cannot be used to replace the missing teeth.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental bridge.
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 the enrollee needs continued care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the services needed could be provided in another setting.
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 enrollee appears to be more stable and improving but still requires additional short-term acute care services for additional weaning, possible thoracentesis, JP drain removal, and strengthening that can safely be received in the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the enrollee is more stable and additional weaning is completed. 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: 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 admission into an IRF is medically necessary. The Plan denied your request. The Plan says you can safely receive services at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation services. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pre-approve Zarxio (Q5101).
You asked the Plan to pre-approve Zarxio. You say that the item is medically necessary The Plan denied your request. The Plan says the claims for routine costs associated with this clinical trial are not payable by the member's plan. Your provider should submit claims to Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Zarxio as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray or pay more for the crown provided by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray and pay more for the crown. You say that you believe these services should be covered in full. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that your benefits for the first intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for services received OON. The Plan contract also clearly states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray, and our intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray or pay more for the crown provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of genicular nerve branches (64624).
You asked the Plan to pre-approve radiofrequency ablation of genicular nerve branches. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met.
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 radiofrequency ablation of genicular nerve branches. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that radiofrequency ablation of the genicular nerves is considered experimental/investigational at this time. This procedure is undergoing clinical trials at this time and the enrollee is not enrolled in a clinical trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of genicular nerve branches have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of genicular nerve branches (64624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral extremity angiography (75716) and abdominal aortography (75625, 75630).
You asked the Plan to pre-approve a bilateral extremity angiography and abdominal aortography. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not needed.
The Plan follows Medicare rules. Medicare rules say that appropriate non-invasive tests should be performed prior to a repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient is deemed unstable and in need of some type of surgical intervention. 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 bilateral extremity angiography and abdominal aortography. Our reviewer says that the criteria for coverage of the requested procedures have not been met. Our physician reviewer found the enrollee has recently undergone diagnostic angiography when he underwent treatment of the right lower extremity. The enrollee presents with symptoms in the left foot and the health plan has approved coverage of imaging and treatment of the left leg. Repeat diagnostic angiography without an associated change in condition is explicitly not covered. 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 bilateral extremity angiography and abdominal aortography have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral extremity angiography (75716) and abdominal aortography (75625, 75630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two simple extractions, one surgical extraction, and four additional removals of residual tooth roots.

You asked the Plan to pay for the extractions and four additional removals of residual tooth roots. You say that you feel these services should be covered. The Plan denied your request. The Plan says two dental extractions have been approved which has exhausted your extractions benefit for the 2020 plan year.

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, extractions are limited to two procedures per calendar year. The record shows that you received six removals of residual tooth roots, two of which were covered by the Plan, and your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two simple extractions, one surgical extraction, and four additional removals of residual tooth roots.