Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 physical therapy (PT) visits.

You asked the Plan to pre-approve 7 PT visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 7 PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have documented skilled therapy needs. Your care needs, as a practical matter, can be provided at a lower 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 7 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided February 4, 2021.

You asked the Plan to pay for the cone beam CT scan and dental consultation. You say that you were told that you could use your dental allowance for any dental services. The Plan denied your request. The Plan says these services are not covered under your dental benefit. Additionally, the Plan states that they have reviewed information provided to you and found no evidence that misinformation was given regarding what is 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. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided February 4, 2021.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Genvisc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the unspecified preventive services (D1999 x 2) provided from June 4, 2020, to June 17, 2020.

You asked the Plan to reimburse you for the limited oral evaluation and the unspecified preventive services. You say that the dentist you saw was listed in the 2020 Provider Directory. You say that you should be reimbursed for the services. The Plan denied your request. The Plan says that limited oral evaluation is not listed as a covered service. The Plan says that unspecified preventive services are not listed as covered services either.

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 reimburse you for the limited oral evaluation (D0140) and the unspecified preventive services (D1999 x 2) provided from June 4, 2020, to June 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Zilretta injection.

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 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 enrollee has right knee osteoarthritis. He received an injection of Zilretta on March 4, 2021 for pain relief. The efficacy and safety of repeat administration of Zilretta have not been demonstrated. The repeat injection is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Zilretta injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) provided November 12, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that the cost of the ambulances services is too high. The Plan denied your request. The Plan says the correct cost-share has been applied to this service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for each one-way covered ambulance trip. 

The enrollee has been asked to pay a $100 copayment for the ambulance services. This service falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) provided November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology care to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve oncology care to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 oncology care to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic CGM (K0553) provided on January 11, 2021.

You asked the Plan to pay for the supply allowance. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code. The Plan also says that the documentation does not indicate the provider discussed the need for the billed supply code.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic CGM (K0553) provided on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the hip replacement provided from October 26, 2020, through October 27, 2020.

You asked the Plan to reduce the coinsurance for the hip replacement. You say that you thought you would be responsible for $490 for one day of inpatient services. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered outpatient hospital visit and hospital outpatient surgical facility.

You have been asked to pay $2,658.05, which is 20% of the allowed amount for the hip replacement. The allowed amount is $13,290.24 (20% x $13,290.24 = $2,658.05). The hip replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the hip replacement was an outpatient procedure. 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 coinsurance for the hip replacement provided from October 26, 2020, through October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prodigy diabetic testing supplies (A4253 and A4259) provided on May 18, 2020.

You asked the Plan to pay for the Prodigy diabetic testing supplies. You say that you believe these items were medically necessary. The Plan denied your request. The Plan says the brand of supplies received is not covered per the enrollee's benefits.

The Plan follows Medicare rules. Medicare rules say that Medicare Advantage organizations may limit coverage to certain DME brands, items, and supplies.

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 Prodigy diabetic testing supplies. Our reviewer says that the Prodigy diabetic testing supplies are not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation that it is medically necessary for the enrollee to use the non-preferred brand of testing supplies (Prodigy) as opposed to the Plan's preferred brand.

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 Prodigy diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Prodigy diabetic testing supplies (A4253 and A4259) provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0150, D0210, D0330, D7210 x8, D0350,
D0160, D0470, D6999 x2, D0367, D9239, D9243 x4, D6010 x6, D6056 x6, D6190, D6119) received from
November 11, 2020, through December 9, 2020.

You asked the Plan to pay for dental services. You say that you do not understand why the Plan did not pay for
any of the services you received. The Plan denied your request. The Plan says there is no coverage when
services are rendered by an out-of-network provider. The Plan also says that most of the dental services at issue
are not covered by the 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of dental services have not been met. Specifically, services were provided by an out-of-network
provider without prior authorization. The Plan has contracted providers available to provide these services. We
found no exception that would require the Plan to pay for these services. Additionally, codes represented by
D0350, D0160, D0470, D6999 x2, D0367, D9239, D9243 x4, D6010 x6, D6056 x6, D6190, D6119 are not
covered benefits. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D0210,
D0330, D7210 x8, D0350, D0160, D0470, D6999 x2, D0367, D9239, D9243 x4, D6010 x6, D6056 x6, D6190,
D6119) received from November 11, 2020, through December 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-radiological diagnostic test provided on August 27, 2020.

You asked the Plan to waive the copayment for special eye evaluation test. You say that you were told the copayment would be waived. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that due to Covid-19, the plan temporarily waived copayments for certain services as a courtesy to you. However, the cost sharing for non-radiological diagnostic services is not eligible for the copayment waiver.

You have been asked to pay a $30 copayment for non-radiological diagnostic test. The record shows the cost sharing for non-radiological diagnostic services is not eligible for the copayment waiver. A special eye evaluation test falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a special eye evaluation test (92060) provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating provider on March 23, 2021.

You asked the Plan to waive the copayment for podiatry services. You say that you do not think that the services you received warrant a $45 copayment. 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 podiatry services/in-network. 

You have been asked to pay a $45 copayment for podiatry services. Since podiatry services were provided, the correct copayment has bene applied. Podiatry services falls within the podiatry services/in-network 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 podiatry services provided by a participating provider on March 23, 2021.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in a different setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. You are refusing to participate in therapy. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 the 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: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve CTA scan of abdomen and pelvis. We decided that the Plan does not have to pre-approve CTA scan of chest.

You asked the Plan to pre-approve CTA scan of abdomen and pelvis. You say that these services are medically necessary. The Plan says that the criteria for the requested services have not been met.

We decided that the Plan has to pre-approve CTA scan of abdomen and pelvis.

The Plan follows Medicare rules. Medicare rules say that CTA scans 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 CTA scan of abdomen and pelvis. Our
reviewer says that the requested CTA scan of the abdomen and pelvis is medically necessary and reasonable, and the CTA scan of the chest is not medically necessary and reasonable. Our physician reviewer found this is a case of a 67-year-old male with a history of emphysema and common iliac artery aneurysm. The CTA of the abdomen would be medically appropriate to monitor the common iliac artery aneurysm. However, given the medical records and medical history of this enrollee is not stated why he would require a CTA of the chest. The enrollee's needs can be mt with a standard CT scan of the chest 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 CTA scan of abdomen and pelvis have been met. We also decided that Medicare rules for coverage of CTA scan of chest have not been met Therefore, we decided that the Plan has to pre-approve CTA scan of abdomen and pelvis.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section 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 does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level and refusal to participate fully in therapy does not support that they require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.