Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6240) for tooth # 30, and the retainer crowns (D6750) for teeth # 29 and 31.You asked the Plan to pre-approvethe dental services. You saythat you have a bridge. You say that one tooth is completely decayed. You say that you cannot eat properly and are in extreme pain. You also say that your dentist advised that the services were urgent.The Plan denied your request. The Plan says the services are not covered.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 dental services 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 dental services. Our reviewer says that the requested dental services do no meet the criteria for coverage. Our physician reviewer found the documentation provided shows the compromise of tooth #31, affecting the integrity of the root canal seal. The reviewer also found that Plan limitations do not provide for posterior fixed prosthodontics. Therefore, there would be no finding of medical necessity for the requested procedure.
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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvea pontic (D6240) for tooth # 30, and the retainer crowns (D6750) for teeth # 29 AND 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveJardiance tablets.You asked the Plan to pre-approveJardiance tablets. You say that you would like theplan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveJardiance tablets.Benefits for Jardiance tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing.
You asked the Plan to pre-approve neuropsychological testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered for certain medical indications. 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 neuropsychological testing. Our reviewer says that the requested neuropsychological testing is not medically reasonable and necessary. Our physician reviewer found that this 67-year-old male is requesting preservice reimbursement for 11 hours of neuropsychological testing beginning December 13, 2019 until June 12, 2020. The records provided showed this enrollee to have been actively using alcohol which is considered counter indicated for neuropsychological testing. Utilizing the criteria from LCD L33632, the enrollee's active alcohol use and depressive symptoms are considered confounding in the administration and interpretation of neuropsychological testing. It does not appear that this enrollee meets the criteria for the administration of neuropsychological testing. The determination of dementia can be obtained through a clinical evaluation without testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail the preferred drug, Retacrit first.
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 Procrit. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of anemia in chronic kidney disease. The Plan requires a trial of drug Retacrit first before they will approve the requested drug, Procrit. The documentation does not show that the enrollee has tried and failed the required drug, Retacrit. The documentation does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
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 SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is independent for bed mobility. The enrollee required modified independence with transfers, 6 stairs, and walking 300 feet with a rolling walker. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of 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 SNF admission 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-approve Vyndamax capsules.
You asked the Plan to pre-approve self-administered drugs. You say that it is absolutely imperative that the enrollee receive this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Vyndamax capsules.
Benefits for 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 pay forobservation care provided on May 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forobservation care. You say that our provider provided medically necessary services to your member in good faith.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 forobservation care provided on May 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sleeves that accompany a compression pump (E0667).You asked the Plan to pay for compression pump sleeves. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery for the date of service does not include the sleeves (E0667) detailed on it.Therefore, we decided that the Plan does not have to pay for sleeves that accompany a compression pump (E0667).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for enrollee.You asked the Plan to pre-approve Euflexxa. You say that the enrollee has found great results with the requested medication as opposed to others.The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to 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 physician reviewer found that the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case.
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 for enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the chemodenervation and BOTOX injections provided September 13, 2019.You asked the Plan to reduce the cost for the chemodenervation and BOTOX injection. You say that you should only be billed a $30 copayment.The Plan denied your request. The Plan says the cost share 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 $30 copayment for provider and professional services at an in-network specialist's office and 20% coinsurance for Medicare Part B covered drugs at an in-network specialist's office. You have been asked to pay a total of $282 for the chemodenervation and BOTOX injection. The chemodenervation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The BOTOX injection 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 for the chemodenervation and BOTOX injections provided September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental extractions (D7140) and alveoloplasty (D7310).You asked the Plan to pre-approvedental extractions (D7140) and alveoloplasty (D7310). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you were already approved your limit of dental extractions (D7140) for the calendar year on January 8, 2020. The Plan states alveoloplasty is not covered under your dental 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 in this case. Your contract clearly states you are covered for up to 2 dental extractions per calendar year. The file shows that you were approved your limit of dental extractions (D7140) for the calendar year on January 8,2020. Your contract also shows that alveoloplasty is not a covered dental benefit.Therefore, we decided that the Plan does not have to pre-approvedental extractions (D7140) and alveoloplasty (D7310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee has late effects of a stroke.The Plan denied your request. The Plan says the enrollee does not have a need for intensive rehabilitation, or multi-specialty involvement.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 physician reviewer found that the enrollee has experienced increased weakness, strength and endurance. A Pre-Admission Screening Form notes that his current level of function entails total assistance with toileting, and maximum assistance with bed, chair/wheelchair, locomotion, and bowel and bladder management. The enrollee is generally medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week or acute rehab nursing care. While he may benefit from continuing physical and occupational therapy, there is 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.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on September 3, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on .You asked the Plan to pre-approve the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 orthosis. Our reviewer says that the services is not medically necessary. Our physician reviewer found the enrollee has no demonstrated joint laxity and the documentation does not show recent surgery.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on .
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve these services. You say that you need the services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have osteoarthritis of both knees. There is no documentation that you have had three months of conservative therapy. There is no record of the impact of the osteoarthritis on your daily activities and no imaging studies supporting a diagnosis of arthritis. The records do not support that Genvisc is reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Genvisc.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity (73221).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage of the MRI have not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found physical examinations by a physiatrist and neurosurgeon note no new or worsening symptoms specifically related to the shoulder. There is no documentation of the enrollee's response to a prescribed course of therapy (meds, injections, therapy). The appropriate test to evaluate for metastasis would be a PET scan/bone scan, not an MRI.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the upper extremity (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed (E0265).You asked the Plan to pre-approvea total electric hospital bed. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds arenot covered.We looked at the file and Medicare rules. Per LCD L33820, total electric hospital beds are not medically necessary, and therefore are not covered.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed (E0265)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that the enrollee needs custom stockings.The Plan denied your request. The Plan says there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that theenrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.