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

We decided that the Plan does not have to pre-approve Durolane (J7318 x 2).

You asked the Plan to pre-approve Durolane. You say that the enrollee has tried and failed the preferred drug Orthovisc. You also say that the requested drug is medically necessary. The Plan denied your request. The Plan says the preferred viscosupplements include Monovisc and Orthovisc. The Plan also says that the enrollee has not tried and failed Monovisc.

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 Durolane. Our reviewer says that the request for Durolane is not medically necessary. Our physician reviewer found the provided documentation states that the enrollee trialed and failed Orthovisc approximately 1 year ago. The reviewer found that the enrollee has not tried viscosupplemental treatment with Monovisc. The reviewer found that the Plan requires that Orthovisc and Monovisc be trialed first. The reviewer found that the documentation does not outline contraindications or reasons that Monovisc was not also considered. Therefore, the reviewer found that without the support of the documentation, Durolane cannot be approved, as step criteria have 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 Durolane have not been met. Specifically, the file does not show that the enrollee has tried and failed Monovisc. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. You say that it is medically necessary for the enrollee to receive this power wheelchair. The Plan denied your request. The Plan says there is no evidence the enrollee's current device is not meeting their needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
The file shows that the enrollee has power wheelchair. This device serves the same purpose as a group 2 power wheelchair and accessories. There is no evidence submitted that this device is broken or otherwise unable to meet the enrollee's needs. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that these injections help your shoulder a lot. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the requested use of Euflexxa is not recommended by the Food & Drug Administration (FDA) or Medicare.
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 Euflexxa. Our reviewer says that you do not meet the Medicare for use of Euflexxa. Our physician reviewer found Euflexxa is not Food & Drug Administration (FDA) approved for your diagnosis. The requested use of Euflexxa is not approved by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Euflexxa.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the problem focused limited oral evaluation. We decided 
that the Plan does not have to pay for the first intraoral periapical x-ray and three resin-based composites.  
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
three resin-based composites. You say that you would like to appeal these services because you are only 
working 8 hours per week. The Plan says that these services are not covered benefits under your insurance 
plan. 
 
We decided that the Plan has to hold you harmless for the problem focused limited oral evaluation.  
 
The Plan must follow Medicare rules. The rules say that the Plan must provide you with a clear and accurate 
description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan 
contract including applicable conditions and limitations and any other conditions associated with the use or 
receipt of the benefits. 
 
The record shows that you received a problem focused limited oral evaluation. The EOC states that oral exams 
are a covered benefit and does not clearly state which type(s) of oral exams are covered. You reasonably 
believed the problem focused limited oral evaluation would be covered because oral exams are listed as a 
covered service. Therefore, we decided that the Plan has to hold you harmless for the problem focused limited 
oral evaluation.  
 
We also decided that the Plan does not have to pay for the first intraoral periapical x-ray and three 
resin-based composites. 
 
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, first intraoral periapical x-ray and 
resin-based composite are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the first intraoral periapical x-ray and three resin-based composites. 
 
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 waive the deductible for out-of-network vision care services you received on November 11, 2019.

You asked the Plan to waive the deductible for the out-of-network vision care services. You say that you were told you only had to pay a $10 copayment. The Plan denied your request. The Plan says at the time of the services, you had only met $340 of the out-of-network deductible. That is way you were charged the full allowed amount of $106.65 (which includes the $10 you paid at the time of the visit and the remaining balance of $96.65).

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 $950 deductible for out-of-network care (except for out-of-network routine physicals, dental care, health and wellness services, hearing aids, preventive care, meals, and smoking cessation classes). After the deductible is met, you pay 40% coinsurance for out-of-network vision services.

The deductible applies to the vision services you received. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $950 deductible for out-of-network care (except for out-of-network routine physicals, dental care, health and wellness services, hearing aids, preventive care, meals, and smoking cessation classes). This cost sharing is a contractual obligation that had not been met at the time the out-of-network vision care services was received on November 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for out-of-network vision care services you received on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on September
10, 2020.
You asked the Plan to pay for services not related to manual manipulation of the spine. You say that these
services should be covered by the Plan. The Plan denied your request. The Plan says they paid procedure code
98941 however, codes 98943, 97012, 29520 and G0283 are not services covered in a chiropractic office.
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 were not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic
services provided to the enrollee on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), gingival irrigation (D4921), extraction (D7210), and drugs or medicaments dispensed in the office for home use (D9630) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that you were in network with the enrollee's Plan on the date of service in this case. The Plan denied your request. The Plan says you are not a network provider. The Plan also says that dental services performed out of network are not covered.
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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), gingival irrigation (D4921), extraction (D7210), and drugs or medicaments dispensed in the office for home use (D9630) provided on March 22, 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the patient has a past medical history of morbid obesity, lymphedema, neuropathy and asthma who is living at home with increasing weakness and trouble walking. Medical problems are stable. There are no complex nursing or rehabilitation needs. In addition, the patient does 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. In conclusion, this is not a reasonable expectation that this patient 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 pay for initial hospital care, per day (99223) provided from
February 3, 2021, through February 12, 2021.
You asked the Plan to pay for initial hospital care, per day (99223). The Plan denied your request. The Plan says there are missing patient medical records for this service.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of initial hospital care, per day (99223) have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care, per day (99223) provided from February 3, 2021, through February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve a walk-in bathtub. You say that your legs are going out and you really need a walk-in bathtub. The Plan denied your request. The Plan says the requested item is not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-rays, unspecified preventive procedure, prefabricated post and core, endodontic therapy, pontics and retainer crowns provided on February 4, 2021.
You asked the Plan to pay for the limited oral evaluation, intraoral x-rays, unspecified preventive procedure, prefabricated post and core, endodontic therapy, pontics and retainer crowns. You say that you paid in full and it should be explained why this is not covered. The Plan denied your request. The Plan says the services are not covered benefits.
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 limited oral evaluation, intraoral x-rays, unspecified preventive procedure, prefabricated post and core, endodontic therapy, pontics and retainer crowns provided on February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.

You asked the Plan to pre-approve SNF services. You say that he is still having difficulty swallowing and may choke on food. You say that the therapist said she can do additional exercises to strengthen that area and therapy should be approved. The Plan denied your request. The Plan says daily skilled services are no longer required and continuation of SNF services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs on a daily basis. Our reviewer also says that the beneficiary does not meet the severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro ConnectBtw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The enrollee has 4/5 upper limb strength. The enrollee is able to perform transfers, toileting, feeding and dressing independently. This strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. The requested accessories are not medically necessary or 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, E2311, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Signatera MRD circulating tumor DNA test provided on November 4, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this specific test is not medically necessary because the enrollee does not have advanced cancer ( Stage IIa,) and the cancer has been removed and requires no further treatment at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Signatera MRD circulating tumor DNA test provided on November 4, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on October 27, 2020.

You asked the Plan to pay for the services provided. You say that the medical records indicate the procedures performed. The Plan denied your request. The Plan says the billed codes cannot be verified.

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 11646 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm. The CPT Code Manual definition of code 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.

We find that the CPT codes are not supported in the medical record. The records do not show that the most comprehensive code was billed for the services performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish (D1208), adjunctive procedure (D9999), and three additional intraoral periapical x-rays (D0230 x3) provided on March 3, 2021.
You asked the Plan to pay for the topical application of fluoride excluding varnish, adjunctive procedure, and additional intraoral periapical x-rays. You say that you were charged for 10 procedures, but only received 3 or 4 of the procedures. The Plan denied your request. The Plan says the topical application of fluoride excluding varnish and adjunctive procedure are not covered services. The Plan also says that your benefits for the additional intraoral periapical x-rays have been satisfied and the frequency limitation has been exceeded.
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 topical application of fluoride excluding varnish (D1208) and unspecified adjunctive procedure (D9999) are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on March 3, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride excluding varnish (D1208), adjunctive procedure (D9999), and three additional intraoral periapical x-rays (D0230 x3) provided on March 3, 2021.