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

We decided that the Plan does not have to pre-approve use of Eylea.

You asked the Plan to pre-approve Eylea. You say that Avastin is not Food & Drug Administration (FDA) approved for your condition, and your physician has had success with Eylea. The Plan denied your request. The Plan says the denial of authorization for Eylea is correct, because the Plan requires a trial of Avastin before it will approve Eylea.

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 Eylea. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Eylea. Our physician reviewer found you have not tried and failed the Plan's preferred drug of Avastin. There is no documentation showing that Avastin would likely be less effective and/or have adverse effects for you. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is a convenience item and not medically necessary or reasonable.

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 total electric hospital bed (E0265).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDx genetic testing provided on March 9, 2021.

You asked the Plan to pay for the ConfirmMDx genetic testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

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 rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

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 specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, we decided that the Plan has to pay for the ConfirmMDx genetic testing provided on March 9, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.

You asked the Plan to pre-approve dental extractions. You say that your teeth are causing several health problems for your cancer and cardiology treatments. The Plan denied your request. The Plan says this service is 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. 

We looked at the file and Medicare rules. In this case, the tooth extractions being requested will not be performed by a dentist incident to a and integral to a procedure performed by the dentist. The tooth extractions are also not being requested to prepare the jaw for radiation treatment of neoplastic disease. Therefore, the tooth extractions are not covered under Medicare. 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 pre-approve dental extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough medical evidence for this procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of the right knee is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received April 14, 2021.
You asked the Plan to pay for the panoramic radiographic image. You say that you want your Plan to pay for dental services. The Plan denied your request. The Plan says the requested service is limited to one procedure every three plan years.
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. The Plan covers panoramic radiographic images, one procedure every three years. We looked at the file, and Medicare rules. The Plan only covers the requested service once every three years. The Plan last covered this procedure on August 12, 2020. When you received the service on April 14, 2020 your benefit was exhausted. You can find this information on page 4-65 of your 2021 EOC. Based on this information, we decided that the Plan's rules for coverage of the panoramic radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthotic foot inserts (item code L3000).
You asked the Plan to pre-approve foot orthotics. You say that you have a lot of problems with your feet and legs and would benefit from this type of insert. The Plan denied your request. The Plan says the denial of authorization for these orthotics is correct, because these are not being requested as part of a covered brace.
The Plan must follow Medicare rules. Medicare rules say that foot inserts with code L3000 are covered if they are part of a covered brace and are medically necessary for proper functioning of the brace. We looked at the file and Medicare rules. These foot inserts are not being requested as part of a covered brace for which they are medically necessary for the proper functioning of the brace. Therapeutic shoes may be covered for enrollees with diabetes under certain circumstances, however the foot inserts with code L3000 do not fall within the category of therapeutic shoes for persons with diabetes. Based on this information, we decided that Medicare rules for coverage of foot orthotics have not been met. Therefore, we decided that the Plan does not have to pre-approve orthotic foot inserts (item code L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation (D9310) received April 12, 2021.
You asked the Plan to pay for the diagnostic consultation. You say that you would like help paying for this claim. The Plan denied your request. The Plan says this service is not covered under your supplemental benefit.
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 diagnostic consultation (D9310) received April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crown (D2740) received April 28, 2021.
You asked the Plan to pay an additional amount for the crown. You say that you need help with this bill. The Plan denied your request. The Plan says you are responsible for any amount over the Plan's $1500 combined preventive and comprehensive dental allowance.
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. The Plan covers dental services up to the $1,500 benefit allowance. We looked at the file, and Medicare rules. Prior to this date of service, you used $807 of your annual dental allowance. The Plan covered $693 towards the crown received on April 28, 2021. This amount exhausted your $1,500 annual allowance for 2021. You are responsible for any amount over and above the Plan's $1,500 annual allowance. This is a cost sharing arrangement you agreed to when you signed up with the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the crown (D2740) received April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoporosis. The documentation does not support that the enrollee has tried and failed Zoledronic Acid. The documentation does not support that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 27, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 provided on January 27, 2021 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services provided on March 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that no authorization was required when done as outpatient. The Plan denied your request. The Plan says services rendered by non-participating providers require 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the testing 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 echocardiography services provided on March 9, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiofrequency ablation of the left knee.

You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624). You say that despite all attempts to relieve pain with a well-managed conservative care regiment over the past year the enrollee continues to experience pain. The Plan denied your request. The Plan says this treatment is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational and is the subject of ongoing clinical trials. Therefore, the request is considered not medically reasonable or 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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiofrequency ablation of the left knee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services provided on February 18, 2021.

You asked the Plan to pay for the occupational therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation. In this case, F02.80 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay for the occupational therapy services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and eye ultrasound provided
on March 30, 2021.
You asked the Plan to waive the copayment for the office visit and eye ultrasound. You say that the EOC states
a $0 copayment for a visual field exam and you shouldn't be charged. The Plan denied your request. The Plan
says the copayments applied correctly.
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 $30
copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care and a $10 copayment for most x-rays and ultrasounds except as specified below.
You have been asked to pay a $30 copayment for the office visit and a $10 copayment for the eye ultrasound. The office visit falls within the "Vision care" benefit category. The eye 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 the office visit and eye ultrasound provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service provided on July 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the anesthesia service. You say that you would like the claim processed under the enrollee's in-network benefits. The Plan denied your request. The Plan says no prior authorization was 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 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 anesthesia service provided on July 28, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services for tooth #19.
You asked the Plan to pre-approve the dental services. You say that your teeth have deteriorated due to recent medical issues. The Plan denied your request. The Plan says the services are not a covered benefit.
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. The file shows that apicoectomy and retrograde filling services were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face down tabletop pillow and a two-way mirror.
You asked the Plan to pre-approve a face down tabletop pillow and a two-way mirror. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a face down tabletop pillow and a two-way mirror are not covered by 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 face down tabletop pillow and a two-way mirror.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sit to stand system.
You asked the Plan to pre-approve the requested item. You say that this is the answer to correct your severe posture issue. The Plan denied your request. The Plan says the system is a convenience item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The file shows that a standing frame with seat lift feature was requested. 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 sit to stand system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (code E0675) provided on January 15, 2021.

You asked the Plan to pay for pneumatic compression device. You say that you believe the Plan has a misunderstanding on the use of the billed Place of Service codes. The Plan denied your request. The Plan says this device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675 is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (code E0675) provided on January 15, 2021.