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

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis demonstrated on physical exam in 2020 and x-ray. There is no documented physical exam or effectiveness or duration of relief from prior injections in the submitted records. Medical necessity of Synvisc-One is not supported by the submitted documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 3) provided on September 24, 2020.
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed as covered services either.
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 limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 3) provided on September 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scan and the ultrasounds
provided on October 6, 2020.
You asked the Plan to waive the copayments for the duplex scan and the ultrasounds. You say that you should
not be charged $258.96. You say you had no choice but to pay this amount. The Plan denied your request. The
Plan says you have been asked to pay 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 $110
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a total of $258.96 copayment for the duplex scan and the ultrasounds. The duplex
scan and the ultrasounds fall 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 copayments for the duplex scan and the ultrasounds provided on October 6,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 25, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says these services cannot be paid as billed due to an issue with the pl ace of service code and the Medicare criteria for the billing of this type of testing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the place of service code reported on the claim is not correct based on where the specimen was reported to have been collected. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer with arthrodesis.
You asked the Plan to pre-approve the spinal 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 spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the interspinous process device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer with arthrodesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the continuous glucose monitor has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cast supplies provided to the enrollee and billed under code Q4010 for dates from August 28, 2020, to September 8, 2020.
You asked the Plan to pay this claim. You say this claim should be covered by the Plan. The Plan denied your request. The Plan says while this claim was partially paid, code Q4010 should be reported once for all cast supplies required for a short arm split. The Plan states that this code is only reported once and is not reported for each roll of fiberglass used in making one cast.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to the frequency in which the code is being billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for cast supplies provided to the enrollee and billed under code Q4010 provided from August 28, 2020 to September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Victory 9 Scooter.
You asked the Plan to pay for the Victory 9 Scooter. You say that you would like reconsideration because the scooter is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that Power Mobility Devices may be covered when specific criteria are met.
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 the Victory 9 Scooter. Our reviewer says that based on the medical records provided, there is no documentation that the member meets the LCD criteria for coverage. Our physician reviewer found the record does not document that the member has a mobility limitation that significantly impairs their ability to participate in MRADLs, that the beneficiary's mobility limitation cannot be sufficiently and safely resolved by use of a fitted cane or walker, that the beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day, that the beneficiary is able to safely transfer to and from a power operated vehicle (POV), that the beneficiary's mental capabilities and physical capabilities are sufficient for safe mobility using a POV in the home, that the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided, that the beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV, that the use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home or that the beneficiary has not expressed an unwillingness to use a POV in the home. 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 Victory 9 Scooter have not been met. Therefore, we decided that the Plan does not have to pay for the Victory 9 Scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of impacted tooth, soft tissue (D7220).
You asked the Plan to pre-approve a removal of impacted tooth. You say that the requested service is medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested service is not covered under your benefit package.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a removal of impacted tooth, soft tissue (D7220).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic medical branch blocks.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet injections are covered when the coverage criteria in the applicable LCD are met. 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 injections. Our reviewer says that the requested pain injections are not medically reasonable and necessary. Our physician reviewer found that the first set of injections did not provide significant pain relief, and therefore, the diagnostic result is negative. They injections should not be repeated. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic medical branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on August 4, 2020, to August 31, 2020.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you should not have to pay for this because you had to wait for the person to do the paperwork. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility (SNF) care/in-network. You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-28 for a skilled nursing stay. The total amount you are being asked to pay is $1,424 ($178 x 8 days = $1,424). A skilled nursing stay falls within the skilled nursing facility (SNF) care/in-network 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 skilled nursing stay provided by a participating provider on August 4, 2020, to August 31, 2020.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or can be tolerated on an IRF level. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the patient has functional goals which would be appropriately addressed through a multidisciplinary inpatient rehab program. The Plan denied your request. The Plan says that the enrollee would be equally well served at an alternative level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to currently perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services (CPT code(s): 97110, 97162, 97112, 97140), to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. You say that you have been going to this provider for years. The Plan denied your request. The Plan says this provider is out-of-network and there are several in-network providers that can provide the 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 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 physical therapy services (CPT code(s): 97110, 97162, 97112, 97140), to be provided by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says step therapy criteria has not been met.

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 Ilumya. Our reviewer says that step therapy criteria has not been met for this drug. Our physician reviewer found the enrollee has not tried and failed or had a contraindication to the plan's step one therapies. The enrollee has been on a non-formulary drug identical in class to one of the plan's preferred agents with good results. The plan's step therapy requirements are not satisfied. Therefore, the requested drug cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab and diagnostic services provided to the enrollee on October 23, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient lab and diagnostic services provided to the enrollee on October 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea for the enrollee.

You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy criteria have not been met.

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 Eylea is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Avastin. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Eylea. 

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 Eylea for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Emerge Auto Emersion Therapy Mattress.

You asked the Plan to pre-approve an Emerge Auto Emersion Therapy Mattress. You say that this is medically necessary. The Plan denied your request. The Plan says that the incorrect code was requested.

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. The file does not include valid documentation that shows the Plan-approved surface would not work or that the requested surface has features that you require that the approved air-fluidized therapy (AFT) mattress does not have. Based on this information, we decided that Medicare rules for coverage of an Emerge Auto Emersion Therapy Mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve an Emerge Auto Emersion Therapy Mattress.