Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 27096 provided on December 19, 2019.
You asked the Plan to pay for CPT code 27096. 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.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. CPT code 27096 has a status indicator of "B" and is not recognized
by OPPS when submitted on an outpatient hospital Part B bill type 13X. Therefore, we decided that the Plan
does not have to pay for CPT code 27096 provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy provided from October 2, 2019 to November 8, 2019.
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were never told there would be a copayment for the radiation. You say you this is a financial hardship and you would like the copayment removed from your record. 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 20% coinsurance for each Medicare-covered radiation therapy service. You have been asked to pay a total of $2,081.29 which is less than the standard 20% of the allowed amount for the radiation therapy. The allowed amount is $11,135.24. ($11,135.24 x 20% = $2,227.05). The radiation therapy 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 coinsurance for the radiation therapy provided from October 2, 2019 to November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant (D6010) provided on February 4, 2020.
You asked the Plan to pay for the endosteal implant. You say that this implant is necessary for your jaw alignment and chewing stability. The Plan denied your request. The Plan says this service is not a covered benefit 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 endosteal implant (D6010) provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse additionally for the urgently needed services and pharmacy services provided on January 2, 2020.
You asked the Plan to reimburse additionally for the urgently needed services and pharmacy services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received urgently needed services while outside the United States on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan and you were reimbursed the correct amount. The Plan says that pharmacy services received outside the United States are not covered.
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 and urgently needed services while outside of the United States. We looked at the file, the Plan's contract and Medicare rules. The file shows you received urgently needed services while out of the country on January 2, 2020. You paid $125 for CPT code 99203, the covered urgently needed visit. Your Plan contract clearly says your copayment for Worldwide urgently needed services received outside of the United States is $90. The file shows the Plan correctly reimbursed you $35 per your contract with the Plan. Medicare rules also say that items and services furnished outside the United States are not covered. The prescription drugs in this case were purchased outside of the United States and no payment can be issued for these items. Therefore, we decided that the Plan does not have to reimburse additionally for the urgently needed services and pharmacy services provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on February 14, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that this service should be covered because the x-ray was taken to determine if there was decay. The Plan denied your request. The Plan says this procedure is not a benefit under the 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. The only x-rays that are covered under your dental benefits are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 for the physician services provided on September 27, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anesthesia for a hip arthroplasty
provided on December 3, 2019.
You asked the Plan to waive the coinsurance for the anesthesia for the hip arthroplasty. You say that you were
told you would be charged as an outpatient. 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 20%
coinsurance for in-network Medicare-covered physician services received while an inpatient during a
Medicare-covered hospital stay.
You have been asked to pay $55.94 which is 20% of the allowed amount for the anesthesia for the hip
arthroplasty. The total allowed amount is $279.70. ($279.70 x 20% = $55.94). The anesthesia for the hip
arthroplasty falls within the "Inpatient hospital care" benefit category. The record shows the surgery is
considered an inpatient surgery.
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 coinsurance for the anesthesia for a hip arthroplasty provided on December
3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRILINTA tablets.
You asked the Plan to pre-approve BRILINTA tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says BRILINTA tablets are not covered under the enrollee's Medicare Part B benefit.
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 BRILINTA tablets.
Benefits for BRILINTA tablets 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: 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 the enrollee has tried other medications but has had better results with Euflexxa and a knee brace. The Plan denied your request. The Plan says the denial of authorization for Euflexxa is 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 does not support than 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 physician services provided on December 23, 2019.
You asked the Plan to pay for the physician 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. In this case, CPT codes G8752 and G8754 have a status indicator of
M and the claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will
accept a corrected claim for payment reconsideration for all claim lines. Therefore, we decided that the Plan
does not have to pay for the physician services provided on December 23, 2019.
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 a Skilled Nursing Facility will not be able to meet your needs, and you need to go to the LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing needs. 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.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve total knee arthroplasty (TKA) surgery.
You asked the Plan to pre-approve TKA surgery. You say that you are appealing with records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee does not meet the Medicare criteria for this procedure.
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty surgery is only covered when the enrollee meets 3 or more of the listed coverage indications and does not meet any of the listed contraindications.
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 TKA surgery. Our reviewer says that the enrollee meets the Medicare criteria for the requested total knee arthroplasty surgery. Our physician reviewer found the enrollee meets 3 or more of the covered indications for this procedure. The following are documented in the records: tricompartmental degenerative changes on Computed Tomography (CT) scan of the knee, X-Rays demonstrating severe degenerative joint disease with medial and lateral joint space narrowing and marginal osteophytes, tricompartmental involvement and subchondral sclerosis, and bone-on-bone findings, failure to respond to an adequate course of appropriate conservative therapy including physical therapy and pain medication, and a distinct structural abnormality. The enrollee does not have any of the listed contraindications to this procedure. The requested total knee arthroplasty is medically reasonable and necessary 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 TKA surgery have been met. Therefore, we decided that the Plan has to pre-approve total knee arthroplasty (TKA) surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care for rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. Your conditions are chronic and do not require admission to an IRF for management. While you may benefit from additional therapies, your functional level does not require or indicate that these therapies must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic devices (L3960, L3916) provided October 3, 2019.
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan denied your request. The Plan says Medicare rules for telehealth consults were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. The record does not show an existing relationship between the prescribing provider and the enrollee. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotic devices (L3960, L3916) provided October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2019.
You asked the Plan to pay for the laboratory 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.
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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to
pay for the laboratory services provided on July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 units of CPT code J0280 provided on December 30, 2019.
You asked the Plan to pay for 3 units of CPT code J0280. 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 the actual number of units
provided for each procedure code.
We find that 3 units of CPT code J0280 are not supported in the medical record. The medical record only
supports 1 unit of CPT code J0280. Based on this information, we decided that Medicare rules for coverage of
3 units of CPT code J0280 have not been met. Therefore, we decided that the Plan does not have to pay for 3
units of CPT code J0280 provided on December 30, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nulojix (belatacept) infusions.
You asked the Plan to pre-approve Nulojix. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says that the requested drug is not medically necessary.
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 Nulojix. Our reviewer says that the
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer
found the enrollee had a lung transplant that has been complicated by chronic kidney disease, in part related to
immunosuppression therapy. Belatacept, which is approved by the FDA for kidney transplantation, has been
used in lung transplantation for patients who develop kidney failure on calcineurin inhibitors (CNI). It is being
used in this enrollee to allow reduction in the dose of CNI to protect the kidneys. Therefore, the enrollee meets
criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Nulojix have been met. Therefore, we decided that the Plan has to pre-approve
Nulojix (belatacept) infusions.
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 a functional electrical stimulator.
You asked the Plan to pre-approve a functional electrical stimulator. You say that a functional electrical stimulator (FES) is safe and effective for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for a functional electrical stimulator.
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 a functional electrical stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee has been prescribed FES devices for use following an intracranial bleed due to a ruptured AVM. According to the applicable NCD, Medicare only covers FES devices for patients with foot drop secondary to a spinal cord injury. In this case the enrollee does not have a history of a spinal cord injury. Medicare otherwise only covers the use of a NMES device for non-neurological reasons for disuse atrophy. In this case the enrollee's reason for disuse atrophy was due to a neurological reason. Consequently, the Medicare requirements for coverage would not be met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a functional electrical stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.