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

We decided that the Plan does not have to pre-approve a Euflexxainjection (J7323). You asked the Plan to pre-approve a Euflexxa injection. You say that the medication is 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 it is expected that an injection (Synvisc-One ?, Gel-One?, Durolane?) or course of the injections (Synvisc?, Hyalgan?, Supartz? or Visco-3?, Euflexxa?, Orthovisc?, GelSyn-3?, GenVisc? 850, Hymovis?, TriVisc?)will not be repeated within six months' time.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 Euflexxa injection. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided the enrollee does not meet the coverage criteria. Repeat injections for shoulder arthritis are limited to a single repeat course.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 Euflexxa injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Euflexxa injection (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions, complete mandibular denture, and complete maxillary denture provided on March 13, 2020 and March 20, 2020.You asked the Plan to pay for the two additional extractions, complete mandibular denture, and complete maxillary denture. You say that you went to the Plan's website and this provider was on the list. You also say that the dentist office told you that they would accept your insurance.The Plan denied your request. The Plan says dentures are not a covered benefit. The Plan also says that the frequency limitation for the extractions benefit has 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, complete mandibular denture and complete maxillary denture are not among those covered under this benefit. The contract also clearly states that extractions are limited to two procedures per calendar year. The record shows that you received four extractions on March 13, 2020, two of which were covered by the Plan, and your extractions benefit has been exhausted.Therefore, we decided that the Plan does not have to pay for the two additional extractions, complete mandibular denture, and complete maxillary denture provided on March 13, 2020 and March 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with vascular dementia and falls, residing in an assisted living facility. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via nasal cannula at night. Regarding rehabilitation services, the beneficiary was at a stand by assist to supervision level for transfers with a rolling walker. She had decreased safety awareness. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX (J7321).You asked the Plan to pre-approveSupartz FX. You say that the service is 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 viscosupplementation therapy is covered when specific criteria is 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 Supartz FX. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided medical records do not document that the enrollee has satisfied the requirements. There is no documentation that the enrollee has failed at least three months of conservative therapy. There is no documentation that the enrollee has failed intra-articular corticosteroid injection therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX (J7321)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown (D2740) and core buildup, including any pins when required (D2950) provided on January 29, 2020.You asked the Plan to pay forthe crown and core buildup. You say that you postponed your second crown because you saw that your maximum benefit was going to increase in 2020, and your copay would decrease in 2020. You also say that you did not know prior to the appointment that crown coverage was eliminated from your benefits.The Plan denied your request. The Plan says these services are not covered benefits under your 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, wedecided that the Plan does not have to pay forthe crown (D2740) and core buildup, including any pins when required (D2950) provided on January 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultrasound and manual therapies to be performed by a chiropractor.
You asked the Plan to pre-approve ultrasound and manual therapies. You say that you have decided to institute this course of care followed by a re-examination. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not covered by Medicare or the Plan when 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 pre-approve ultrasound and manual therapies to be performed by a chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable with an old stroke and right hemiplegia and aphasia with no recent neurological or Orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. Currently the enrollee is at max assist to dependent for activities of daily living and mobility with no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF stay will not significantly change the enrollee's functional status in a predicted period of time especially when base line function itself was low. Based on review of the available records, the enrollee does not meet criteria for coverage for an admission to an IRF. Admission to an IRF is not medically necessary based on medical stability and low functional status.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ostomy supplies provided on December 13, 2019  by an out of network (OON) provider.You asked the Plan to pay for the ostomy supplies. You say that Medicare does not require prior authorization for urinary supplies. Previous payments were made without prior authorization with current provider status. Please reprocess for payment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered 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 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 ostomy supplies provided on December 13, 2019  by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac (SI) joint nerves.
You asked the Plan to pre-approve the RFA of the SI joints. You say that this treatment is necessary to reduce the enrollee's low back pain. The Plan denied your request. The Plan says criteria for this treatment are not 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 the RFA of the SI joints. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Low back pain. The enrollee underwent lateral branch blocks of L5, S1, S2, and S3 on 4/29/20. She reported around 75% relief in her pain for 8 - 10 hours, and that her functionality was over 90% better. Physical examination revealed severe tenderness to deep pressure over the bilateral sacral iliac areas, and negative straight leg tests. There was no weakness. Reflexes were normal. Small clinical trials evaluating radiofrequency ablation for chronic sacroiliac joint pain have generally shown that RFA may modestly reduce pain in the short-term; however, there does not appear to be clear long-term clinical benefit. As such, this is not considered medically reasonable and 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 of the SI joints have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac (SI) joint nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) provided on November 25, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 the office visit (99202) provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation and intraoral x-rays provided on February
13, 2020.
You asked the Plan to pay for the oral evaluation and intraoral x-rays. You say that the charges are reasonable
and should be covered. You say that you should be reimbursed $160. The Plan denied your request. The Plan
says out-of-network dental services are 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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral
evaluation and intraoral x-rays provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forto pay for exercise equipment purchased February 26, 2020.You asked the Plan to pay forthe exercise equipment. You say that you were told by a plan representative that equipment is covered.The Plan denied your request. The Plan says exercise equipment is not covered under Medicare or the Plan.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only membership in a qualified health club or fitness facility.The Plan's rules for coverage of gym benefits have not been metbecause exercise equipment does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay forto pay for exercise equipment purchased February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the silver/black wheelchair shroud and a 22 inch backrest cloth cover coded with two units of code K0108.You asked the Plan to pre-approve the wheelchair shroud and backrest cloth cover. You say that the enrollee requires this power wheelchair for mobility.The Plan denied your request. The Plan says the chair and all components have been approved aside from the shroud and backrest cloth cover as these do not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Though these items may be appropriate, they do not meet the definition of durable medical equipment.Therefore, we decided that the Plan does not have to pre-approve the silver/black wheelchair shroud and a 22 inch backrest cloth cover coded with two units of code K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the intravitreal injections provided from February 19, 2019 to August 6, 2019.
You asked the Plan to waive the copayments for the intravitreal eye injections. You say that the services were done at an eye clinic and not at a surgical center. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for each in-network Medicare-covered outpatient procedure in a hospital or ambulatory surgical center (ASC). You have been asked to pay a $295 copayment for the intravitreal eye injections on each date of service. The intravitreal eye injections fall within the "Outpatient hospital services" benefit category. The record shows you were billed by an outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the intravitreal injections provided from February 19, 2019 to August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for platelet rich plasma plus an allograft injection of the knee.You asked the Plan to pay for the regenerative therapy. You say that you would like reconsideration because you had to pay for these services up front.The Plan denied your request. The Plan says you do not have out of network coverage and these services are still being studied.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 regenerative therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found these procedures are experimental/investigational and you were 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 the regenerative therapy have not been met.Therefore, we decided that the Plan does not have to pay for platelet rich plasma plus an allograft injection of the knee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 thecase 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on reviewof the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs acute rehab nursing care. Functionally given her current level with Dementia, question her ability to retain learned skills in therapies in an IRF and hence does not require IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tattooing services (11921) provided on September 18, 2019.
You asked the Plan to pay for the tattooing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 11921 is tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm. We asked our coder 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 tattooing. Our reviewer says that CPT code 11921 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not include the size of the area to support this code. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tattooing have not been met. Therefore, we decided that the Plan does not have to pay for tattooing services (11921) provided on September 18, 2019.