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

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not gone through a step therapy program.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not show that the enrollee has tried and failed Reclast. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. In addition, Evenity is not indicated for treatment of osteopenia.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 6 home health physical therapy visits and an additional 3 home health occupational therapy visits.
You asked the Plan to pre-approve the additional physical therapy and occupational therapy home health visits. You say that there has been measure progress from past physical and occupational therapy, but that it has been slow because of limited us of the enrollee's arm. You say that the additional visits which remain in dispute are necessary for the enrollee's continued progress. The Plan denied your request. The Plan says the rules for additional home health services have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 additional physical therapy and occupational therapy home health visits. Our reviewer says that an additional 6 home health physical therapy visits and an additional 3 home health occupational therapy visits are not medically necessary. Our physician reviewer found the skilled services of physical therapy and occupational therapy are not required to treat the enrollee's illness or injury, to improve the enrollee's condition, to maintain the enrollee's condition, or to prevent deterioration of the enrollee's condition beyond what was approved by the health plan. The enrollee's functional level is at a point where she does not need ongoing professional skilled physical therapy or occupational therapy. The enrollee should be able to transition to an independent home exercise 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 the additional physical therapy and occupational therapy home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 6 home health physical therapy visits and an additional 3 home health occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visit (92014) provided on November 19, 2019.
You asked the Plan to waive the deductible for the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ophthalmological services on November 19, 2019. At the time of services rendered you had not met your $600 deductible; therefore, you have been asked to pay $129.56 for the services to apply to your deductible. 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 deductible for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visit (92014) provided on November 19, 2019.
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 Synvisc-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Synvisc-One. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that you have tried and failed Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects. Therefore, you do not meet step therapy 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99326), avulsion of nail plate (11730), and the nail debridement (11721) provided on July 23, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99326), avulsion of nail plate (11730), and the nail debridement (11721) provided on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for(CPT code G0249) provided from August 13, 2018 through August 12,2019 by an in-network provider.You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claims were processed accordingly with your 2018 and 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the services from August 13, 2018 through August 12, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the services. 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(CPT code G0249) provided from August 13, 2018 through August 12, 2019 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bathroom rails and toilet rails.You asked the Plan to pre-approve the rails. You say that you cannot get into and out of the shower without falling.The Plan denied your request. The Plan says these rails are not covered by Medicare.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 bathroom rails and toilet rails.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that your tub is too small for alternative devices
and the requested shower bench is not a convenience item for you. You say that the requested shower bench
has bars to help you get out of the tub. You stated that you have not been able to wash your feet in years and
you cannot do as much due to your multiple medical conditions. The Plan denied your request. The Plan says
this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) and bitewings - four radiographic images (D0274) provided on January 21, 2020 by an in-network
provider.
You asked the Plan to pay for the dental services. You say that the provider used the wrong codes. The Plan
denied your request. The Plan says the services are not a covered benefit under the 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 services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for comprehensive oral
evaluation - new or established patient (D0150) and bitewings - four radiographic images (D0274) provided
on January 21, 2020 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9946) provided on January 6, 2020.
You asked the Plan to pay for the occlusal guard. You say that prior to receiving this service you spoke with a
plan representative who told you that everything was good. You also say that the procedures you had done
were important in order to be able to keep your own teeth. 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
occlusal guard (D9946) provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that the services are not medically necessary. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that only one caudal or lumbar interlaminar injection is approved per session. We looked at the file and Medicare rules. The request is for two lumbar ESIs in one session. The Plan has approved one ESI. A second lumbar ESI is not covered by Medicare. 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 a second lumbar epidural steroid injection (ESI).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha 140 mg/ml sureclick (J3590).
You asked the Plan to pre-approve Repatha 140 mg/ml sureclick. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Repatha 140 mg/ml sureclick (J3590).
Benefits for Repatha 140 mg/ml sureclick 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 11, 2019 through February 12, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 11,2019 through February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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. 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 a lumbar-sacral orthosis (L0650) provided to the enrollee on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on March 29, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you were not informed of 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 20% coinsurance for DME and related supplies. You received DME on March 29, 2019. The allowed amount is $2,899.50 and 20% of that is $579.90. You have been asked to pay the total coinsurance amount of $579.90 for DME. DME falls within the DME and related 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 DME provided on March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a power wheelchair power seat elevation feature.
You asked the Plan to provide a power seat elevation feature (E2300). You say that the power seat elevation feature is necessary to allow the enrollee to reach for meal prep and grooming. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan follows Medicare rules. Medicare rules say that options for wheelchairs are covered if the option is medically necessary. A power seat elevation feature does not serve a purpose that is primarily medical in nature. This means that Medicare rules for coverage of the feature have not been met. Therefore, we decided that the Plan does not have to provide a power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 4, 2019. You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for (CPT Code 52649) provided to the enrollee from  March 25, 2019 through April 4, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Current Procedural Terminology (CPT) code 52649 (1 unit) remains not supported. The submitted medical records not indicate that laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete was performed. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Therefore, we decided that the Plan does not have to pay for(CPT Code 52649) provided to the enrollee from  March 25, 2019 through April 4, 2019.