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

We decided that the Plan does not have to pay for the bronchoscopy rendered on November 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 31654 is not supported.
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 31654 is Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s]). We find that CPT code 31654 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 pay for the bronchoscopy rendered on November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection does not meet the step therapy guidelines. Our physician reviewer found there is no evidence of a trial and failure of zoledronic acid. The documentation does not support that Zoledronic acid 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99212 provided on August 5, 2019.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are included in the payment of other services.
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 99212 is office or other outpatient visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: A problem
focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or
coordination of care with other physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or
family.
We find that CPT code 99212 is not supported in the medical record. Specifically, this was a post-operative
visit. Payment for these services are included in the surgical procedure payment provided on July 29, 2019.
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit coded 99212 provided on August 5,
2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the heart.
You asked the Plan to pre-approve CT scan. You say that you believe this is medically necessary. The Plan
denied your request. The Plan says that the denial of authorization for this service is correct, because this CT
scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that you
meet the Medicare criteria for the requested CT scan. Our physician reviewer found you have an intermediate
risk for coronary artery disease (CAD) and some atypical symptoms. You also have a family history of CAD
and an elevated low-density lipid (LDL) cholesterol, though you are not currently on statin therapy. Coronary
calcium scoring for you would be indicated based on current guidelines to further refine your risk and
determine whether possible testing or initiation of statin lipid lowering therapy is warranted. Following
Medicare rules, this testing is therefore indicated and medically necessary based on published literature
guidelines and your specific clinical situation, as the results of this test will impact therapy and ongoing 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve
a Computed Tomography (CT) scan of the heart.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric services provided from July 7, 2019 to July 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for the inpatient psychiatric services. You say that the services were necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider at issue in this case is not a network provider with the Plan. 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 inpatient psychiatric services. Our reviewer says that the services were not medically necessary. Our physician reviewer found based on review of the records provided, this enrollee does not meet the criteria for acute inpatient mental health treatment.The enrollee was not shown to be a danger to himself or others, was without agitation or aggression, and without perceptual disturbance including auditory, visual hallucinations or delusions.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 inpatient psychiatric services have not been met. 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 pay for the inpatient psychiatric services.Therefore, we decided that the Plan does not have to pay for inpatient psychiatric services provided from July 7, 2019 to July 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on March 29, 2019.
You asked the Plan to pay for the office visit. You say that you were not told that an office visit to a
chiropractor would not be covered by the health plan. The Plan denied your request. The Plan says these
services are 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 (99203) provided on March 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug does not meet the step therapy guidelines. Our physician reviewer found there is no indication of a trial and failure of Orthovisc and Monovisc. The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc injections for the right knee.
You asked the Plan to pre-approve the Orthovisc injections. You say that viscosupplementation is needed to
treat the enrollee's arthritis pain. The Plan denied your request. The Plan says that new literature findings show
that this type of treatment is not effective and is no longer recommended.
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 the Orthovisc injections. Our reviewer
says that the requested Orthovisc treatment is considered medically reasonable and necessary. Our physician
reviewer found this enrollee presents status post right knee arthroscopy with medial meniscectomy, lateral
meniscectomy, and chondroplasty on 4/17/19 with persistent and significant right knee pain and intermittent
swelling. She had reportedly failed to achieve adequate relief with post-operative conservative treatment,
including aspiration and corticosteroid injection, physical therapy, bracing, home exercise program, and
medications.
Under consideration is a request for a series of three Orthovisc injections to the right knee. Evidence based
medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain
in patients with osteoarthritis of the knee. Current evidence based medical guidelines state that medical
evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some
patients. A trial of Orthovisc injections is reasonably indicated for treatment of this enrollee's knee pain given
the failure of operative and non-operative treatment and worsening pain and functional limitations. Therefore,
the request for Orthovisc injections would be considered medically reasonable and necessary at this time for
treatment of the enrollee's right knee osteoarthritis.
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 Orthovisc injections have been met. Therefore, we decided that the Plan has
to pre-approve Orthovisc injections for the right knee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that you are on dialysis and have to be an appointment to do post-op testing for a kidney transplant. The Plan denied your request. The Plan says the rules for coverage have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each trip does not exceed 50 miles one-way. We looked at your request, the records in the case file, and the rules. The records show that the requested trip is more than 50 miles from your home. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940, 98941) provided by out of network (OON) from August 7, 2019 to October 30, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the services were provided by an out of network provider without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940, 98941) provided by the out of network (OON) provider from August 7, 2019 to October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next EZ (A4253) test strips.
You asked the Plan to pre-approve Contour Next EZ (A4253) test strips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested Contour Next EZ test strips are not covered.
The Plan must follow Medicare rules. The rules say that a Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. Your contract with the Plan clearly states the Plan covers any blood glucose monitors and test strips specified within the preferred brand list. The requested Contour Next System is not a preferred meter though the Plan. Furthermore, your provider was contacted and states that you are able to use any brand test strips. Based on this information, we decided that Medicare rules for coverage of Contour Next EZ (A4253) test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next EZ (A4253) test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on January 30, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says theclaim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that youreceived the office services provided on January 30, 2020. You are asked to pay a $50 copayment for the office services. The Plan's vision vendor processed and paid the refraction exam in full, with no member cost share. The only appealable issue, is the copayment for office 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 forthe office visit provided on January 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not 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 only in a SNF. The skilled services are not needed 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 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital admission provided from October 5, 2019 to October 15, 2019.
You asked the Plan to pay for inpatient hospital admission. You say that you are appealing the determination and requesting a review of the medical records for subsequent reversal of the denial. The Plan denied your request. The Plan says that following the emergency department evaluation, the patient received appropriate consultation and a short period of observation (observation status might have been appropriate for this episode). The member could have returned home, or to a sub-acute nursing facility (as arranged by the PACE interdisciplinary team) for further treatment and observation.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 inpatient hospital admission. Our reviewer states that the service was medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) on October 5, 2019 with a complaint of chest pain after dialysis. In the ED she appeared with normal vital signs. An electrocardiogram (EKG) demonstrated normal sinus rhythm with no acute changes. She was admitted to telemetry and evaluated by Cardiology and Neurology. Her medical regimen was altered. She underwent a transthoracic echocardiogram (TTE) and a left heart catheter. Her condition stabilized and improved. She was discharged home with scheduled outpatient follow-up on October 15, 2019. The review has determined that the inpatient hospital services October 5, 2019 through October 15, 2019 were medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital admission have been met. Therefore, we decided that the Plan has to pay for inpatient hospital admission provided from October 5, 2019 to October 15, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of area physician services provided on November 19, 2019.
You asked the Plan to pay for the out of area physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows the office visit was not due to an unforeseen illness or condition. The file shows the office visit was neither emergent nor urgent and prior authorization was not obtained. Based on this information, we decided that Medicare rules for coverage of the out of area physician services have not been met. Therefore, we decided that the Plan does not have to pay for the out of area physician services provided on November 19, 2019