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

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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 medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was medically stable without any acute exacerbations of chronic medical problems. It is unclear what her prior physical function was given her confused mental status reporting her prior level of function (PLOF) as independent but after a 4-day hospital stay she is maximum assistance with many tasks. It is unclear if she is at or near her baseline and if she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that based on the medical records provided, the member has not tried and failed Orthovisc and Monovisc. Our physician reviewer found the medical records do not indicate that the Plan's required drugs would likely be less effective and/or have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig. 
 
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 Aimovig.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that rehab is necessary transition for the member to go 
home. The Plan denied your request. The Plan says that the enrollee's therapy needs can be provided 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 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. The 
patient with Debility with no evidence of need for supervision by physical medicine and rehab physician or 
need for acute rehab nursing care. Functionally given her current level, though she needs physical therapy (PT) 
and occupational (OT), she does not require IRF level of therapies. The patient may benefit from further PT 
and an OT but does not require an intensive therapy program. IRF admission is not medically necessary due to 
lack of medical complexity. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Prolia. Our reviewer says that based 
on the medical records provided, the member has not tried and failed  zoledronic acid, Our physician reviewer 
found there is no indication in the medical record that the Plan's required drug would likely be less effective 
and/or likely have adverse effects. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two osseous surgeries (D4260 x2) provided on March 18, 
2020. 
 
You asked the Plan to pay for the osseous surgeries. You say that you would like the Plan to reconsider the 
payment for these services. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
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 pay for the two 
osseous surgeries (D4260 x2) provided on March 18, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member does not appear to require intensive daily therapy and 
requires minimal assistance. 
 
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. The 
patient is medically stable with no evidence of need for supervision by physical medicine and rehab physician 
or need for acute rehab nursing care. Functionally given his current level, though he needs physical (PT) and 
occupational therapy (OT), he does not require IRF level of therapies. The patient may benefit from further PT 
and OT but does not require an intensive therapy program. IRF admission is not medically necessary based on 
the patient?s lack of medical complexity. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral tissue biopsy (D7286) provided on March 19, 2020.
You asked the Plan to pay for the oral tissue biopsy (D7286). You say that this needed to come out to ensure no
cancer existed. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the 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 pay for the oral
tissue biopsy (D7286) provided on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B drugs (intravitreal injection of a pharmacologic agent (67028) bevacizumab Injection, 0.25 mg (C9257)) and facility services provided November 27, 2019 to December 9, 2019.
You asked the Plan to waive the copayment for the Part B drugs and facility services. You say that you are on a fixed income and your insurance agent said you are only supposed to pay for the eye shots only and no copayment. The Plan denied your request. The Plan says the claims were processed and the correct cost share was applied per the plan benefits.
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 20% coinsurance for each Medicare covered Part B drug and a $415 copayment for Medicare covered surgery or other services provided at an outpatient hospital for Medicare Part B Prescription Drugs and Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. You have been asked to pay $573.84 ($286.92 + $286.92). The Part B drugs and facility services falls within the Medicare Part B Prescription Drugs and Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit categories. 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 Part B drugs (intravitreal injection of a pharmacologic agent (67028) bevacizumab Injection, 0.25 mg (C9257)) and facility services provided November 27, 2019 to December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cannabinoids and stimulants laboratory testing provided on October 22, 2019.
You asked the Plan to pay for the cannabinoids and stimulants laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services the enrollee received are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80349 and 80371 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these services are 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 cannabinoids and stimulants laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the cannabinoids and stimulants laboratory testing provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography and bilateral breast tomosynthesis rendered on April 22, 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 codes 77067 and 77063 were not billed correctly.
The Plan must follow Medicare rules. The rules say that the medical record must reflect that the modifier is being used appropriately to describe separate services. We looked at the file and Medicare rules. The provider billed procedure codes 77067 and 77063 with anatomical modifier -RT. This modifier is not appropriate, as these are bilateral codes. Therefore, we decided that the Plan does not have to pay for the screening mammography and bilateral breast tomosynthesis rendered on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of
intraoral x-rays provided on March 12, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that your provider contacted the Plan to see if you qualified for x-rays, and was told you did. You also say
that you are on a fixed income and are unable to come up with the payment to cover these services. The Plan
denied your request. The Plan says the benefits for these services have been satisfied and the frequency
limitations have 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, exams (including periodontal exam
and comprehensive oral evaluation) and are limited to one procedure every three years. The record shows that
you received a comprehensive oral evaluation on February 25, 2019, and your periodontal exam and
comprehensive oral evaluation exam benefit has been exhausted. The contract also clearly states that full mouth
or panoramic x-rays are limited to one procedure every five years. The record shows that you received a
complete series of intraoral x-rays on February 25, 2019, and your full mouth or panoramic x-rays benefit has
also been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation and complete series of intraoral x-rays provided on March 12, 2020.
Your complaint about being misled by the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCR testing provided on July 29, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically
necessary.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that commercial stool panels are widely available for the convenience of stool pathogen testing by
providers and their patients. While validated, these panels are often overreaching and overly broad, and not
medically justified by Appellant's available records. The available records support that the enrollee has limited
comorbidities and that her mushy stool was chronic and uncomplicated. Neither patient nor provider
convenience justify as "standard of care" nor by Plan or conventional definition of "medical necessity" a shotgun
diagnostic approach in routine testing of uncomplicated diarrheal illness in lieu of otherwise targeted stool
analysis.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the PCR testing provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from February 26, 2020 to March 4, 2020.
You asked the Plan to pay for the services. 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from February 26, 2020 to March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a post-op office visit provided by a participating provider on January 3, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a follow-up visit. You say that there should be no charge for this. 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 $45 copayment for physician/practitioner services/specialist office visit. You have been asked to pay a $45 copayment for a specialist office visit. Follow-up appointments are still subject to copayments; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist office visit 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 post-op office visit provided by a participating provider on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be coded with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are required for swelling in the arm. The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.