Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the representative said this service is covered. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prolia.

You asked the Plan to pre-approve Prolia. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.

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 the requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a trial of an intravenous bisphosphonate before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug(s) 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 treatment with Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for endodontic therapy (D3330) provided on January 4, 2021, the prophylaxis (D1110) provided on January 30, 2021 and the core buildup (D2950) provided on February 23, 2021.

You asked the Plan to pay more for the endodontic therapy, prophylaxis and core buildup. You say that there is a limited selection of highly skilled providers approved by the dental program in your region. You say that the dental payment amounts should be reconsidered at the in-network coverage status. The Plan denied your request. The Plan says the claims processed correctly.

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 Plan paid their share of the cost for your covered services. You are responsible for any remaining amount above the Plan paid amount for dental services received from an out-of-network provider in addition to the coinsurance. Therefore, we decided that the Plan does not have to pay more for endodontic therapy (D3330) provided on January 4, 2021, the prophylaxis (D1110) provided on January 30, 2021 and the core buildup (D2950) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and bitewing x-rays provided on April 6, 2021.
You asked the Plan to pay for the limited oral evaluation and bitewing x-rays. You say that you were not aware the dentist was no longer in-network. You say that you are asking for insurance to pay for the service. The Plan denied your request. The Plan says your plan does not cover services from a provider who is not in-network.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and bitewing x-rays provided on April 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on January 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider 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 an outpatient surgery provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) and ultrasound
(97035) provided April 5, 2021 to May 11, 2021.
You asked the Plan to pay for the chiropractic services. You say that you are appealing because previous claims
with the same procedures, modifiers and diagnoses were paid. The Plan denied your request. The Plan says
these services are not covered under the Plan 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 service at issue is not manual manipulation of the spine. The claim was also billed
with the modifier code GA which indicates that patients knows that the service do not meet the guidelines for
coverage and has indicated that he or she wants the services performed despite non-coverage. Therefore, we
decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) and ultrasound
(97035) provided April 5, 2021 to May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy treatments.

You asked the Plan to pre-approve the sclerotherapy. You say that these veins need to be treated since they are causing pain. The Plan denied your request. The Plan says the criteria for coverage of this treatment are not met.

The Plan follows Medicare rules. Medicare rules say that tributary veins may be treated with sclerotherapy when the veins are greater than 4mm in diameter and symptoms have not improved after conservative treatments. 

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 sclerotherapy. Our reviewer says that the requested treatment is not considered medically necessary based on LCD coverage guidelines. Our physician reviewer found the record indicates that the enrollee has diabetic neuropathy and venous insufficiency with telangiectasia. The provided records do not indicate that a venous duplex has been performed to evaluate for reflux. The vessels are not reported to be greater than 4 mm. The provided records are insufficient to demonstrate that the elements of the coverage criteria are 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy treatments.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided from
February 1, 2021 to February 12, 2021.

You asked the Plan to pay for the home health service. You say that the services were previously approved as a
covered benefit. The Plan denied your request. The Plan says the provider did not bill as required by Medicare
coding regulations. The Plan says that a Medicare ID number for the facility is not on file. The Plan also says
that if you determine that a billing error occurred during the initial submission of the denied claim, the plan will
accept a submission of a corrected claim to consider services for payment.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home visit for hemodialysis (99512)
provided from February 1, 2021 to February 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab.

You asked the Plan to pre-approve Rituximab. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.

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 Rituximab. Our reviewer says that the requested Rituximab is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Ruxience, Truxima, and Rituxan Hycela before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on February 13, 2021.

You asked the Plan to pay for the pin retention. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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.

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 pin retention (D2951) provided on February 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procalamine.

You asked the Plan to pre-approve Procalamine. You say that this request is medically necessary. The Plan
denied your request. The Plan says all drugs used for the treatment of end stage kidney disease are included in a
bundled payment to the dialysis facility and are not separately paid.

The Plan must follow Medicare rules. Medicare rules say that ESRD facilities are responsible for furnishing
these drugs directly or under arrangement and are not separately payable.

We looked at the file and Medicare rules. In this case, the enrollee's ESRD facility would be responsible for
payment even though they are not supplying these drugs at the ESRD facility. Based on this information, we
decided that Medicare rules for coverage of Procalamine have not been met. Therefore, we decided that the
Plan does not have to pre-approve Procalamine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive evaluation (D0150), bitewing x-rays (D0274) and dental cleaning (D1110) provided on April 13, 2021.
You asked the Plan to pay for the dental services. You say that this provider was on the list of approved dentists and these services should be covered. The Plan denied your request. The Plan says the Plan network shown on the submitted forms is not your specific dental network. The provider in question has opted out of Medicare participation and therefore no payment can be made.
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. You may choose to see any dentist, so long as that dentist has not affirmatively opted out of Medicare or has been excluded from Medicare participation. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services are not covered under this benefit when they are received from a dentist who does not participate in the Medicare program. The provider in this case has opted out of Medicare participation. The dental network listed with the providers on the appeal documentation is a network with your dental insurance provider, but this network is not the same as your specific network with the dental plan. Therefore, we decided that the Plan does not have to pay for the comprehensive evaluation (D0150), bitewing x-rays (D0274) and dental cleaning (D1110) provided on April 13, 2021.
Your complaint about a potential lack of clarity or confusion regarding your dental network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection services rendered on December 1, 2020.

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 procedure code 67500 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 67500 (retrobulbar injection; medication [separate procedure, does not include supply of medication]) and 00140 (anesthesia for procedures on eye; not otherwise specified). Code 67500 is a column II code with a modifier indicator of 1 when billed with column I code 00140. Code 67500 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pre-approve the injection services rendered on December 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429-QL) provided on October 6, 2020.

You asked the Plan to pay for the ambulance service. You say that the service was necessary. The Plan denied your request. The Plan says ambulance service with no transport is not covered by Medicare.

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 A0429-QL is Ambulance service, basic life support, emergency transport (bls-emergency). 

We find that CPT code A0429 is not supported in the record. Specifically, it is not appropriate to bill CPT code A0429 with modifier QL. There is a more appropriate CPT code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429-QL) provided on October 6, 2020.
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 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 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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. 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation and other services to recover and regain your prior level of function before going home. The Plan denied your request. The Plan says the criteria for an IRF are not met, and you can receive the care you need in another setting.

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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 

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: Favorable

We decided that the Plan has to pay for trimming of dystrophic nails, any number (G0127) paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided April 14, 2021.
You asked the Plan to pay for the foot care visit. You say that you have type 2 diabetes and has to have your feet checked every 3 months. You cannot afford this because you take so much medicine and only get social security every month. The Plan denied your request. The Plan says that the coverage criteria has not been met as there is no medical documentation that supports coverage of this claim.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the foot care visit. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is well established in the medical documentation that this enrollee is suffering with thick painful toenails. This diabetic enrollee is noted to have absent posterior tibial pulses, thick painful toenails, callouses, absent pedal hair growth, thin skin, with decreased turgor. These findings meet the class B findings necessary for coverage of routine foot care. In summary, this enrollee is noted to have diabetes with class B findings which would put their foot at risk if routine foot care is not performed by a professional. Therefore, it is my opinion that the routine foot care provided on 4/14/2021 meets Medicare guidelines and can be considered medically reasonable and 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 the foot care visit have been met. Therefore, we decided that the Plan has to pay for trimming of dystrophic nails, any number (G0127) paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided April 14, 2021.
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.