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

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323).You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee will benefit from Euflexxa.The Plan denied your request. The Plan says the documentation does not support the Plan's medical necessity guidelines for coverage.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Euflexxa injections. Our reviewer says that the service does not meet the coverage criteria. Our physician reviewer found the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer found that the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer also found that the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. 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 Euflexxa injections have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee from August 3, 2019 to August 10, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not include documentation to validate that an independent trained observer was present to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older as required to validate that CPT code 99152 was performed on August 3, 2019, August 9, 2019 and August 10, 2019. We looked at this coder'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 pay for moderate sedation services (CPT 99152) provided to the enrollee from August 3, 2019 to August 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 9, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because you feel that an ultrasound is not considered a radiological diagnostic service. 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 $200 copayment for each radiological diagnostic service. You have been asked to pay the allowed amount of $118.57, which is less than the $200 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs to be provided by an out of network (OON) provider.You asked the Plan to pre-approve wheelchair repairs. The Plan denied your request. The Plan says that medically necessary care is available in 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 5, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a post-operative X-ray provided on June 6, 2019.
You asked the Plan to pay for the post-operative X-ray. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a post-operative x-ray provided on June 6, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay fora Positron Emission Tomography and Computed Tomography (PET-CT) scan provided on December 20, 2019.You asked the Plan to pay for PET-CT scan. You say that you received an approval letter telling you to get this test.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network and the service was available within the Plan network.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records of this service or any documented attempts to obtain such medical records. Without this information, we cannot determine whether this service meets the criteria for urgent out-of-area care. Therefore, the Plan has not shown that its decision to deny payment is correct or medically justified. Therefore, we decided that the Plan has to pay fora Positron Emission Tomography and Computed Tomography (PET-CT) scan provided on December 20, 2019. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an implant body (D6010) provided on January 22, 2020.
You asked the Plan to pay for the dental service. You say that you received approval for this service on October 29, 2019. You also say that this process takes several months to complete and involves 3 different phases. The Plan denied your request. The Plan says the surgical placement of an implant are 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 surgical placement of an implant is not among those covered under this benefit. Additionally, the record shows that on the approval you received on October 29, 2019, it clearly says that approval does not guarantee that the plan will pay for the service. Therefore, we decided that the Plan does not have to pay for the surgical placement of an implant body (D6010) provided on January 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had extensive prior therapy visits for your condition. The documentation reveals slow improvement and that you are at a functional level that does not require ongoing skilled therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 24, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not told that the provider you saw was a specialist. You say the insurance company should pay for this. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 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 copayment for the specialist office visit provided on September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home occupational therapy (OT) services.You asked the Plan to pre-approve the OT services. The Plan denied your request. The Plan says the OT services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 OT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the documentation does not support the need for the requested therapy. The enrollee is more than 6-8 months post-stroke and has received therapies earlier. He needs to practice hand writing and fine motor skills he learned in earlier therapy sessions. It is not accepted, specific and effective therapy for the patient's condition of having difficulty to write. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist.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 OT services have not been met.Therefore, we decided that the Plan does not have to pre-approve in-home occupational therapy (OT) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 36 additional non-emergency trips for routine transportation. You asked the Plan to pre-approve the additional trips. You say that this is needed to get to dialysis. The Plan denied your request. The Plan says the request is not covered by the benefit plan. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 36 additional non-emergency trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2750) provided on November 8, 2019.You asked the Plan to reimburse you for the dental service. You say that you had a broken tooth. You say that you needed a crown. You also say that you have out of network coverage.The Plan denied your request. The Plan says regardless of the provider's network status, crowns are not 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 crown is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the crown (D2750) provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a Superion spacer.You asked the Plan to pre-approve the procedure. 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications have not been met for the Superion procedure.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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve implantation of a Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for a second back-up wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is needed until the primary wheelchair is repaired and adjusted.
The Plan must follow Medicare rules. The rules say that a backup wheelchair is not considered reasonable or necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. As backup chairs themselves are not considered necessary by Medicare, repairing them also cannot be considered medically necessary. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs for a second back-up wheelchair for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for an x-ray provided on December 31, 2019.
You asked the Plan to waive the copayment for an x-ray. You say that you were told that you would only have a $100 copayment. You say that the hospital is saying you now owe $160. The Plan denied your request. The Plan says that the correct copayments have been applied.
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 enrollees must pay $0 for outpatient diagnostic tests/PET scan. The Plan says you must pay a $60 copayment for an x-ray. Information was provided to show that the $60 was incorrectly applied. The total amount you owe is $100 for a PET scan. Therefore, we decided that the Plan has to waive the copayment for an x-ray provided by Saratoga Hospital on December 31, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole tablets.You asked the Plan to pre-approve Pantoprazole. You say that this is necessary to treat the enrollee's GERD.The Plan denied your request. The Plan says coverage of this medication is the responsibility of Medicare Part D.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Pantoprazole tablets.Benefits for Pantoprazole may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, and crown provided on November 12, 2019 and November 26, 2019.
You asked the Plan to pay for the core buildup and crown. You say that when you purchased this plan several years ago, you were told that a percentage of all dental work would be covered. You also say that you were not informed some procedures would not be covered and were not told that it was your responsibility to call the Plan prior to getting a procedure to see if it was covered. The Plan denied your request. The Plan says core buildup is not a covered benefit. The Plan also says that the crown was processed according to the Plan's negotiated rate.
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, core buildup are not among those covered under this benefit. The contract also clearly states that you must pay a 70% coinsurance for crowns when they are received by an in-network provider. The record shows that you were appropriately charged for this service. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required, and crown provided on November 12, 2019 and November 26, 2019.
The records show that you also disputed the Plan's denial of root canal therapy provided on August 8, 2019. The case file does not show that the Plan made a reconsideration determination on this portion of your appeal. You may contact the Plan directly regarding the status of their review for that dispute.