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

We decided that the Plan does not have to pre-approve Epogen (J0885).
You asked the Plan to pre-approve Epogen. You say that Epogen is medically necessary. The Plan denied your request. The Plan says a trial of Retacrit is required before alternatives like Epogen can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Epogen. Our reviewer says that Epogen is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drug or any reason why the plan preferred drug would be unsafe or ineffective 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 Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen (J0885).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta (J2505).
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Neulasta is covered for patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of severe febrile neutropenia. 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 Neulasta. Our reviewer says that Neulasta is not medically necessary. Our physician reviewer found the documentation does not support that the member has greater than a 10% risk of febrile neutropenia. The documented incidence of febrile neutropenia in patients treated with this cancer regimen/drug is less than 10%.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta (J2505).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is needed to alleviate the enrollee's chronic pain. The Plan denied your request. The Plan says the services are 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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on February 25, 2021, and March 30, 2021.

You asked the Plan to pay for the gingival irrigation and drugs or medicaments. You say that the Plan only paid for one gingival irrigation, but not the other three. You also say that only one drugs or medicaments were issued and the other was for the gel used during the procedure. The Plan denied your request. The Plan says these services are not covered under the 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 gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on February 25, 2021, and March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for group psychotherapy provided on January 28, 2021 by an out of network provider.

You asked the Plan to pay for group psychotherapy (90853). You say that the telehealth services were provided under the enrollee's benefit. The Plan denied your request. The Plan says they did not authorize the non-urgent services.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for group psychotherapy provided on January 28, 2021 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for group psychotherapy provided on January 7, 2021 by an out of network provider.

You asked the Plan to pay for group psychotherapy (90853). You say that the telehealth services are covered under the enrollee's outpatient benefit. The Plan denied your request. The Plan says you did not request 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for group psychotherapy provided on January 7, 2021 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspiration remains experimental. More research is needed to show safety and efficacy of bone marrow aspiration when used as a bone graft in surgery. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve bone marrow aspiration (20939) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment (98940) rendered by the out of network (OON) provider from October 8, 2020, through February 5, 2021.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 issue reimbursement 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 had network providers available who could have provided 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 issue reimbursement for these services.

Therefore, we decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment (98940) rendered by the out of network (OON) provider from October 8, 2020, through February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to predominantly base metal (D2751) received May 4, 2020.
You asked the Plan to pay for the crown. You say that the dental office confirmed that crowns were covered. The Plan denied your request. The Plan says the requested service is not listed under your covered benefits for 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, the requested items or services are not among those covered under this benefit. Dental code D2751 does not appear on the list of covered codes in
your 2020 Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for the crown -
porcelain fused to predominantly base metal (D2751) received May 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for abdominal aortic aneurysm (AAA) screening (76706).
You asked the Plan to pay for the AAA screening. You say that you feel the procedure was billed wrong. Code 76706 is not for the ultrasound you had. Code 76706 is a one-time deal and you have an ongoing problem with the aneurysm. The Plan denied your request. The Plan says the benefit has been exhausted.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers an AAA benefit in excess of Medicare coverage, the benefit has been exhausted. The records show this benefit was provided October 1, 2018. Therefore, we decided that the Plan does not have to pay for abdominal aortic aneurysm (AAA) screening (76706).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment provided on March 4, 2021.
You asked the Plan to pay for the acupuncture treatment. The Plan denied your request. The Plan says lower back pain was not a billed diagnosis.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic lower back pain (CLBP) meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file, the Plan's rules and Medicare rules. The file shows that the claim was not billed with the diagnosis of chronic lower back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers acupuncture for chronic lower back pain. Therefore, we decided that the Plan does not have to pay for acupuncture treatment provided on March 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on February 26, 2021.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you disagree with the denial. 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 $0 copayment for each diagnostic mammogram and a $130 copayment for radiological diagnostic services. You have been asked to pay a $130 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI), spinal canal and contents, cervical; without contrast material (72141) provided on January 5, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $325 per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.

You have been asked to pay a $273.14 copayment for the Medicare-covered diagnostic radiology service provided. This is the Plan allowed amount which is less than the applicable copayment for this service. 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 adjust the copayment for the magnetic resonance imaging (MRI), spinal canal and contents, cervical; without contrast material (72141) provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered when ordered through the pharmacy. Please note that the Plan has indicated they will cover the drug at issue when re-ordered and provided by a physician.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication was ordered to be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and debridement provided on March 3, 2021 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care and debridement. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.

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 subsequent nursing facility care and debridement provided on March 3, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional splinting (D4321) and sales tax (D9985) provided on January 28, 2021.

You asked the Plan to pay for the provisional splinting and sales tax. You say that if you did not have this work done you would have lost your tooth. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 provisional splinting (D4321) and sales tax (D9985) provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 29, 2021by an out of network (OON) provider.

You asked the Plan to pay for outpatient services. You say that the member's primary care physician referred these services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 outpatient services provided on January 29, 2021by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a history of fracture or a trial of Zoledronic acid is required before Prolia can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the record shows no history of fracture. The record shows no reason the plan preferred drugs would be unsafe or ineffective. 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 60mg/ml (J0897).
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 LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee can receive all necessary services in the current facility.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with acute respiratory failure and possible aspiration pneumonia due to COVID-19 requiring steroids, remdesivir, and supplemental oxygen. Nasogastric (NG) tube feeds were administered. Recent notes show that he is still receiving feeds via NG tube and is still requiring high-flow oxygen with low lung volumes, pulmonary vascularity and diffuse airspace disease seen on imaging, stable from prior imaging.

The patient appears to be more stable but still requires additional short-term additional acute care services to further wean from oxygen and to stabilize a more permanent feeding method, that 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. Therefore, this request for LTACH services will be considered not medically necessary 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 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.