Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0299) provided on July 6, 2020, and July 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare. In the great majority of cases, these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837I. We looked at the file and Medicare rules. As code G0299 is a home health service code, it must be billed on an institutional claim. The home health services in question were not billed on home health claim. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (G0299) provided on July 6, 2020, and July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on August 24, 2020.
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that there are no medical records showing that the prescribing physician ever saw the member.
The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during a intraoperative neuromonitoring (IONM) on May 28, 2020 billed with code 95999.
You asked the Plan to pay for the TOF testing. You say that all services should be paid due to medical necessity. The Plan denied your request. The Plan says all codes were approved for payment except for code 95999 which is not an appropriate code.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. TOF testing is an integral part of IONM services. As such, it is not appropriate to separately bill for this service. Therefore, we decided that the Plan does not have to pay for the train-of-four (TOF) testing provided during a intraoperative neuromonitoring (IONM) on May 28, 2020 billed with code 95999.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections (J7321).
You asked the Plan to pre-approve Hyalgan injections. You say that Hyalgan injections are medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives like Hyalgan can be considered.
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 injections. Our reviewer says that Hyalgan injections are not medically necessary. Our physician reviewer found the record does not show a trial of both plan preferred drugs, or any reason why they would be unsafe or ineffective for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections (J7321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available. The enrollee's needs are met at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is needed for home use. The Plan denied your request. The Plan says the records do not show that the enrollee's home is appropriate for this wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation is not clear why the enrollee's mobility deficit is unable to be helped by the use of a manual wheelchair given her upper extremity strength of 4/5 and recommendations by the DME consulting group to use a manual wheelchair. The documentation indicates the enrollee has cognitive deficits and has had prior falls on her scooter. It is unclear whether she has the appropriate cognitive skills needed to safely operate the PMD. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on September 15, 2020 and September 23, 2020.
You asked the Plan to pay for the chiropractic services. You say that you were following your chiropractor's treatment plan and you did not know the services would not be covered. The Plan denied your request. The Plan says the services are not covered benefits.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on September 15, 2020 and September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on September 8, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that no one told you there would be a copayment at a different lab. 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 $50 copayment for laboratory services at an in-network outpatient hospital. You have been asked to pay a $50 copayment for the laboratory services. The laboratory services fall 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 the laboratory services provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that covered repairs for the wheelchair have already been paid up to the cost of the wheelchair replacement.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 repairs. Our reviewer says that the requested repairs are not medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit but it is not clear that it impairs participation in MRADLs in the home. The mobility deficit can be helped by a walker and it is not clear why you cannot use a manual wheelchair. The documentation is not clear that you can safely maneuver the PMD in the home with adequate space. The documentation indicates the expense of repairs that were paid exceeds wheelchair replacement therefore the criteria for repairs has not been met. 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 repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), the unspecified preventive service (D1999 x 3), the core build up (D2950), the crown (D2740), and the periapical x-ray (D0220) provided from August 20, 2020, to September 9, 2020.
You asked the Plan to reimburse you for the dental services. You say that you have a previous claim from this provider that was paid. You say that you were advised by the dental office that there is a government error and that the provider has not actually opted out of Medicare. You also say that the Annual Notice of Changes for 2020 says that the plan covers up to $2,250 of dental services for non-Medicare covered services and therefore you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services that you receive from a provider that has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), the unspecified preventive service (D1999 x 3), the core build up (D2950), the crown (D2740), and the periapical x-ray (D0220) provided from August 20, 2020, to September 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic, prophylactic, or diagnostic injection (96372) and aripiprazole, extended release, 1 mg injection (J0401) provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for injection of aripiprazole. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for services rendered by an out-of-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 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 had network providers available who could have provided 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 a therapeutic, prophylactic, or diagnostic injection (96372) and aripiprazole, extended release, 1 mg injection (J0401) provided on September 11, 2020 by an out of network (OON) provider.
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to currently require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the physician's services. 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 physician's services provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visit and diagnostic eye 
exam provided on May 12, 2020, and August 21, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital visit and diagnostic eye exam. You say that 
the services should be covered. The Plan denied your request. The Plan says the cost share was 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 Medicare-covered exams to diagnose and treat diseases and conditions of the eye for vision 
care. Your contract with the Plan also clearly says that you must pay a $20 copayment for all other Medicare- 
covered services received in an outpatient hospital facility. 
 
You have been asked to pay a $30 copayment for Medicare-covered eye exams and $20 for outpatient hospital 
visit. 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 outpatient hospital visit and diagnostic eye exam 
provided on May 12, 2020, and August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a dental prophylactic procedure (D1110) 
received on August 7 and for dental fillings (D2393, D2331) received on August 26, 2020. 
 
You asked the Plan to waive the cost-sharing for dental prophylaxis and dental fillings. You say that you were 
told by a representative of the Plan that your dental provider is in-network. The Plan denied your request. The 
Plan says the correct cost-sharing was 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 $25 
copayment for covered preventive and diagnostic services, a $100 deductible for optional supplemental 
benefits, and 20% coinsurance for basic dental services (minor restorative) after the annual deductible is met.  
 
You have been asked to pay a $25 copayment for dental services on August 7 and August 26, 2020; a $100 
deductible for dental services on August 26, 2020; and $146.08 coinsurance, or 20% of the Medicare-allowed 
amount of $230.40, for dental services on August 26, 2020. Dental prophylaxis falls within the "Dental 
services" benefit category. Dental fillings fall within the "Optional Supplemental Dental Services" benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost-sharing for a dental prophylactic procedure (D1110) 
received on August 7 and for dental fillings (D2393, D2331) received on August 26, 2020.  
 
Your complaint about receiving erroneous or ambiguous information about your Plan's provider network from 
a representative of the Plan is not a valid appeal for medical coverage. Your complaint about being charged for 
the balance of your dental bill by an out of network dental provider is not a valid appeal for medical coverage. 
These parts of your complaint are grievances that must be answered by the Plan. Medicare does not permit us 
to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device. 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has low back pain. The requested spacer is considered 
experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituxan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has neutropenia. The documentation does not support that the requested use of 
Rituxan is FDA-approved for the enrollee's diagnosis. The requested drug is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.