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

We decided that the Plan does not have to pre-approve Photodynamic Therapy with Verteporfin.
You asked the Plan to pre-approve Photodynamic Therapy with Verteporfin. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested service is 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 Photodynamic Therapy with Verteporfin. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has dense cicatricial banding and symlephara interfering with maintaining a ocular prosthesis. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Photodynamic Therapy with Verteporfin have not been met. Therefore, we decided that the Plan does not have to pre-approve Photodynamic Therapy with Verteporfin.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance transportation services.
You asked the Plan to pre-approve the air ambulance transportation services. You say that you need to get to Kentucky to be close to your daughter for aid. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of air ambulance services.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. The case file shows that the air ambulance services are being requested as a method of transport for the enrollee to be closer to family for care. This is not a covered indication for air ambulance services. Based on this information, we decided that Medicare rules for coverage of the air ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve air ambulance transportation services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the enrollee was on Alendronate for over 5 years and lost bone density. The Plan denied your request. The Plan says the documentation does not show that the enrollee meets the criterion.
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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs, oral and intravenous bisphosphonates (Alendronate, Risedronate and Zoledronic Acid), for 1 year before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug, Zoledronic Acid. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on April 13, 2021.
You asked the Plan to pay for the dental service. You say that you called your dentist office to see what type of x-ray you had done. You say that you were advised it was a diagnostic x-ray. You also say that your dentist needed to do this type of x-ray to make sure that there was not an active abscess or infection. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service.
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 periapical x-ray (D0220) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00520) provided on January 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for anesthesia services. You say that the anesthesiologist should not be penalized. You also say that obtaining authorization would be the surgeon/facilities responsibility and not the member as he did not have a choice to pick the anesthesiologist. The Plan denied your request. The Plan says 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 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. services were provided by an out-of-network provider without prior authorization. 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 anesthesia services (00520) provided on January 20, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied towards lab services you received on January 14, 2021.

You asked the Plan to waive the deductible applied towards the lab services. You say that these lab services were ordered as part of your annual physical, so there should be no deductible applied. The Plan denied your request. The Plan says you were not charged anything for the annual wellness visit you had on January 18, 2021. However, the lab services are not part of this visit, so the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $200 annual deductible that applies to lab services.

You had not yet met your deductible when you had these lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 annual deductible that applies to lab services. Your contract also clearly says that lab services are not included in your annual physical or annual wellness exam and that separate cost sharing applies for lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on January 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied towards lab services you received on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted arthroscopy procedures on the musculoskeletal system (29999) provided September 2, 2020.

You asked the Plan to pay for the procedure. You say that there is no CPT code for an arthroscopic repair, therefore you are billing this with an unlisted procedure code, 29999. The Plan denied your request. The Plan says procedure code 29999-LT is not supported by the medical records submitted.

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 29999 is unlisted arthroscopy procedures on the musculoskeletal system. 

We find that CPT code 29999 is not supported in the medical record. Specifically, the narrative of the operative report does not include documentation of an unlisted arthroscopy procedure. There is a more appropriate CPT code 29806, which is inclusive to 29827. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted arthroscopy procedures on the musculoskeletal system (29999) provided September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2020 by an out-of-network (OON) provider.

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 the services were rendered 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 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 the laboratory services provided on February 25, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 5, 2021 by an outof-
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like the Plan to pay for this. You say
this was for an annual wellness exam. The Plan denied your request. The Plan says the rendering physician is
out-of-network.
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 physician services provided on February 5, 2021
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device with moderate sedation.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated moderate to severe severe spinal stenosis at multiple levels. The record does state that operative treatment is not indicated at more than two levels. The record does not indicate relief in flexion. The elements of the coverage criteria are not satisfied. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device with moderate sedation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and an electronic connection.
You asked the Plan to pre-approve a power seat elevation system and an electronic connection. You say that the items in dispute are medically necessary. The Plan denied your request. The Plan says the items in dispute are not covered by Medicare or under the enrollee's contract.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a power seat elevation feature and electrical connection devices with the sole function of connection for a power seat elevation or power standing feature are non-covered.
The items at issue in this appeal are a power seat elevation feature and an electronical connection device with the sole function of connection for a power seat elevation feature. These items are non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and an electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no permanent problem with the digestive tract.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the limited provided documentation, there was no clear approved indication for parenteral nutrition such as an issue not being able to safely take nutrition via oral route. Therefore, this request for parenteral nutrition will be considered not medically necessary based on the provided records. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for individual therapy visits via telehealth provided on January 19, 2021, and May 25, 2021.
You asked the Plan to waive the copayments for individual therapy visits via telehealth. You say that you are unhappy to pay these charges when the copayments were waived last year. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $25 copayment for each individual therapy visit via telehealth. You received individual therapy visits via telehealth on January 19, 2021, and May 25, 2021. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $50. You have been asked to pay the total copayment amount of $50 for individual therapy visits via telehealth. Individual therapy visits via telehealth fall within the physician/practitioner services, including doctor's office visits 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 copayments for individual therapy visits via telehealth provided on January 19, 2021, and May 25, 2021.
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 you are unable to take care of yourself and require these services. The Plan denied your request. The Plan says that your rehabilitation needs are not complex and do not require an interdisciplinary approach with multiple specialists to oversee your rehabilitation care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 this care is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the rules for LTACH care have 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 that the patient is a 50-year-old female who was admitted to the current acute care
hospital with altered mentation and increased shortness of breath after missing one week of dialysis for her end
stage renal disease. The patient appears to be improving, requiring only short-term additional acute care
services to further wean and stabilize which can be safely completed at the current facility. The patient does not
require services at the LTACH that are not already available at the current facility. In addition, there are no
services at the LTACH that the patient requires that are not already available and covered at the current
facility.
Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time
would not provide a clinical advantage. Transfer may be considered when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #19.
You asked the Plan to pre-approve the crown. You say that you need a crown because a root canal was done on this tooth. The Plan denied your request. The Plan says a crown is only covered one (1) time in a 60-month period (5 years). The Plan also says that that you had a crown on tooth #19 completed on December 14, 2020.
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, a crown (D2751) is limited to 1 per tooth per 60 months. The record shows that you received a crown on tooth #19 on December 14, 2020 and your crowns benefit for tooth #19 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PCD (CPT code E0675RR), for the enrollee.
You asked the Plan to pre-approve the DME. You say that based on the enrollee's condition, you are aware that E0675 does not meet criteria for Medicare guidelines. You state you need authorization denial to deny as enrollee responsibility. The Plan denied your request. The Plan says this is discussed with the enrollee prior to delivery and a signed waiver was obtained. The Plan states the enrollee's surgery was cancelled, but now rescheduled.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Centers for Medicare and Medicaid Services LCD: Pneumatic Compression Devices L33829, states; A high-pressure pneumatic compression device is used only for peripheral artery disease. The enrollee does not have a diagnosis of peripheral artery disease. Therefore, the requested high-pressure pneumatic compression device is denied. Therefore, we decided that the Plan does not have to pre-approve the PCD (CPT code E0675RR), for the enrollee.