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

We decided that the Plan does not have to pre-approve KRYSTEXXA.
You asked the Plan to pre-approve KRYSTEXXA. You say that the enrollee has tried other medications but KRYSTEXXA is necessary and warranted. The Plan denied your request. The Plan says the enrollee hasn't tried first, second, and third line treatments before trying KRYSTEXXA.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve KRYSTEXXA. Our reviewer says that KRYSTEXXA is not medically necessary. Our physician reviewer found The American College of Rheumatology treatment guideline for gout does not recommend use of KYSTEXXA until the patient has failed treatment with first-, second-, and third line treatments for gout (allopurinol, febuxostat, and probenecid). According to the documentation provided, the member has not failed the treatments as listed above. The review has determined that the documentation does not support that the KRYSTEXXA is medically reasonable and necessary for the patient. The documentation does not support that the KRYSTEXXA is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of KRYSTEXXA have not been met. Therefore, we decided that the Plan does not have to pre-approve KRYSTEXXA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve talking scale (E1369).You asked the Plan to pre-approvetalking scale. You say that you were given a talking scale after an emergency room visit and it is now broken. You need to weigh yourself daily to monitor your condition and you need a talking scale because you are blind.The Plan denied your request. The Plan says this item is not a covered benefit.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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to enrollee by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that driving to an in-network provider would be exhausting.The Plan denied your request. The Plan says there are capable providers within the 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. ThePlan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided to enrollee by an out of network (OON) provider.
Appeal type: Step-Therapy
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 you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug was correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Euflexxa.
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 Euflexxa. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation submitted does not show that Orthovisc and Monovisc would likely be less effective and/or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services are available from equally qualified providers within the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on June 17, 2019.
You asked the Plan to reimburse you for the dental service. You say that you had to have an infected tooth removed from your mouth. You say that the provider was billed as out of network. You say that the oral exam was denied. You also say that it should be covered as the exam was performed prior to removing your tooth. The Plan denied your request. The Plan says the oral exam is dental in nature. The Plan says dental services are not covered by your medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The service you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on June 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on July 22, 2019.You asked the Plan to pay for the chest x-ray. You say that you are allowed to bill separately for the professional and technical components of this service. The Plan denied your request. The Plan says when a provider under the same Tax Identification Number (TIN) performs both the professional component and a technical component of a code, they need to bill globally.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the record. Specifically, it is never appropriate for the technical and professional components to be unbundled andreported separately under the same TIN number. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forwound care provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay forwound care. You say that you did not get prior approval because delay in services could result in wound complications.The Plan denied your request. ThePlan 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 has network providers available who can provide 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 forwound care provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a MRI provided on November 9, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you cannot afford the charges. 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for an MRI. An MRI 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 a MRI provided on November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that the enrollee requires a full coverage
restoration on tooth #13 due to a fracture of the remaining tooth structure. You also say that this tooth is the
only tooth that the enrollee is using to chew on the left side. The Plan denied your request. The Plan says
Medicare does not cover this 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care from 7:08 PM on August 24, 2019 to August 28, 2019.
You asked the Plan to pay for inpatient care. You say that these were emergency services. The Plan denied your request. The Plan says the enrollee was stable as of 7:08 PM on August 24, 2019. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the services after 7:08 PM on August 24, 2019 were post-stabilization care and do not meet the criteria for coverage. Our physician reviewer found the enrollee was stabilized on August 24, 2019 and should have been considered for transfer to an approved facility. Alternatively, approval could have been sought for ongoing care at the same hospital. A request for pre-approval was not initiated as required by the plan. Without the request or granted pre-approval, post stabilization care (care delivered after emergency department stabilization) cannot be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care from 7:08 PM on August 24, 2019 to August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that due to a bicycle accident, the
partial denture you had suffered damages and you are unable to use it now. The Plan denied your request. The
Plan says this service is allowed one time in 5 years. The Plan also says that their records show you have
already had this service within the past five years and have reached the limit for this 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, mandibular partial dentures are limited
to 1 per 5 calendar years. The record shows that you received a mandibular partial denture (D5214) on
February 5, 2019 and your mandibular partial dentures benefit is now exhausted. Therefore, we decided that the
Plan does not have to pre-approve the mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the canalith repositioning procedure provided on October 30, 2019.You asked the Plan to waive the copayment for the canalith repositioning procedure. You say that this was performed at a previously scheduled appointment. You say that you were not informed of any additional expense prior to the procedure.The Plan denied your request. The Plan says that the copayment applied correctly.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 covered services include consultation, diagnosis and treatment by a specialist. The Plan says you must pay a $25 copayment for the canalith repositioning procedure. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the canalith repositioning procedure. The canalith repositioning procedure is considered a physician service, which is included in the office visit copayment.Therefore, we decided that the Plan has to waive the copayment for the canalith repositioning procedure provided on October 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical bone growth stimulator (E0747).
You asked the Plan to pre-approve electrical bone growth stimulator. You say that your doctor has told you that a bone growth stimulator is needed to help the acromion bone heal. Therefore you contacted a company to send the stimulator to you. The Plan denied your request. The Plan says the medical notes provided by the provider show that you have a fracture of the acromion which is not considered a long bone and therefore does not meet the criteria.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve electrical bone growth stimulator (E0747).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee and billed under codes G0483. You asked the Plan to pay for codes G0483and 80307. You say that this claim should be paid.The Plan denied your request. The Plan says while the Plan approved code 80307, the physician documentation required for code G0483 was not submitted.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat the enrollee as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee and billed under codes G0483 and 80307.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the addition of a tooth to an existing partial denture for tooth #20.
You asked the Plan to pre-approve the addition of a tooth to an existing partial denture for tooth #20. The Plan denied your request. The Plan says this service is 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. 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 the addition of a tooth to an existing partial denture for tooth #20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee wants to use FreeStyle Lite test strips. The Plan denied your request. The Plan says there was no additional information submitted to support medical necessity for the non-preferred brand of test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrodes (A4556) and needles (A4215) provided on November 12, 2019.You asked the Plan to pay forelectrodes and needles. You say that this should be paid because you were inpatient at an in-network facility.The Plan denied your request. The Plan says these items are not covered.The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.We looked at the file and Medicare rules. The record indicates that you were inpatient at the time these items were provided. The hospital is responsible for paying for these items. Based on this information, we decided that Medicare rules for coverage of electrodes and needles have not been met.Therefore, we decided that the Plan does not have to pay forelectrodes (A4556) and needles (A4215) provided on November 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 18, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not want to be charged for the services received on May 18, 2019 which were the same services received on May 14, 2019. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received treatment in the emergency room on May 18, 2019.
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 emergency room visit provided on May 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient referral for Hyperbaric Oxygen Therapy (99183) to be provided.
You asked the Plan to pre-approve the Hyperbaric Oxygen Therapy. You say that you have a lung infection and the services requested are medically necessary. The Plan denied your request. The Plan says no referral for the Hyperbaric Oxygen treatment was received from your Primary Care Physician. Insufficient medical records have been provided to determine if the service is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The record shows three attempts were made by the health plan to obtain medical records to determine if the service requested was medically necessary. No clinical records were received. A referral for these services was not furnished by your PCP. Based on this information, we decided that Medicare rules for coverage of the Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve an outpatient referral for Hyperbaric Oxygen Therapy (99183) to be provided.