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

We decided that the Plan does not have to pay for specialist services provided on January 7, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 specialist services provided on January 7, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99213) received on March 5, 2021.
You asked the Plan to pay for the services. You say that the services were rendered for your cancer diagnosis. The Plan denied your request. The Plan says this code is considered bundled into the global surgical package for that procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99213 is "Office or other outpatient visit for the evaluation and management of an established patient." We find that CPT code 99213 is not supported in the medical record. Specifically, this code cannot be billed separately and should be considered part of the surgical procedure. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for office visit services (CPT 99213) received on March 5, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve diabetic shoes and inserts from the physician referred out-of-network provider.

You asked the Plan to pre-approve for diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe (A5500) and for diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each (A5513). You say that the requested provider is the only supplier who carries the diabetic shoes and can make them for the enrollee. The Plan denied your request. The Plan says that they have in-network providers that can provide the service and items.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not identified an in-network provider who can fit, follow-up and custom prepare diabetic shoes and inserts. The Plan named one provider that was a mail order company. Therefore, we decided that the Plan has to pre-approve diabetic shoes and inserts from the physician referred out-of-network provider.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.

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 drug is not eligible for a tier exception.

The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D. 

We looked at the file and Medicare rules. The requested drug is covered under Part B Medicare and is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).

You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Monovisc and Orthovisc. The Plan also says that the Part B 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 Synvisc. Our reviewer says that Synvisc is not medically necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc, the plan's preferred drugs. The reviewer found that the provided documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that Synvisc is not approved as step criteria have not been met. 

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 have not been met. Specifically, the enrollee has not trialed and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286), the bone replacement graft (D4263), and the guided tissue regeneration (D4266) provided on March 31, 2021.

You asked the Plan to pay for the dental services. You say that you were never told about the out of network provider status. You say that you were in pain You say that you received the recommended surgery. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says the dental services that you received are not listed as covered service. The Plan also says that you signed a treatment plan prior to the date of service acknowledging the $0 Plan payment and accepting responsibility for the cost of the 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 incisional biopsy of oral tissue, the bone replacement graft, and the guided tissue regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286), the bone replacement graft (D4263), and the guided tissue regeneration (D4266) provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2790) provided on February 1, 2021.
You asked the Plan to pay for the crown. You say that you would like to appeal this service. The Plan denied your
request. The Plan says the crown code (D2790) is not a covered dental service under your 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 crown (D2790)
provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 18, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 physician services provided on August 18, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a participating provider on March 13, 2021.

You asked the Plan to waive the copayment for diagnostic radiology services. You say that you do not agree with this copayment. 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 $50 copayment for outpatient diagnostic tests/. 

You have been asked to pay $47.17 which is less than your copayment amount of $50 for diagnostic radiology services. The correct copayment has been applied to the services that were provided. Diagnostic radiology services fall within the outpatient diagnostic tests/ 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 diagnostic radiology services provided by a participating provider on March 13, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral nutritional product.

You asked the Plan to pre-approve the product. You say that this is medically necessary. The Plan denied your request. The Plan says enteral nutrition products that are administered orally are non-covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve an oral nutritional product.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee
.
You asked the Plan to pre-approve the device. You say that an enrollee with lymphedema can qualify for E0652 regardless of cause. The Plan denied your request. The Plan says this is not a covered benefit for chronic venous insufficiency.

The Plan must follow Medicare rules. Medicare rules say that E0652 is not covered for chronic venous insufficiency. 

The requested pneumatic compression device is coded with E0652 and is being requested for chronic venous insufficiency. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee is being followed for
multiple lung nodules. The Plan denied your request. The Plan says criteria is not met for a LDCT.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the above described criteria.
We reviewed the file and the Medicare rules. The record shows the enrollee is not a current smoker or one who
has quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a low dose
computed tomography (LDCT) scan for lung cancer screening
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the health problem.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH care 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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43235).
You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that this is indicated for the enrollee's iron deficiency anemia. The Plan denied your request. The Plan says the enrollee has not had a negative colonoscopy.
The Plan must follow Medicare rules. Medicare rules say that diagnostic esophagogastroduodenoscopies are indicated for presumed chronic blood loss and for iron deficiency anemia when a colonoscopy is negative. We looked at the file and Medicare rules. While the records show that the enrollee has iron deficiency anemia, the records do not show that he has had a negative colonoscopy. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43235).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you had this procedure done in 2017, but since then you have had to have all but 6 front teeth removed. The Plan denied your request. The Plan says this service is allowed one time in 5 calendar years. The Plan also says that you have already had this service within the past 5 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, maxillary dentures are limited to 1 per
5 calendar years. The record shows that you received a maxillary partial denture (D5213) on March 27, 2017
and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan
does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oncology office visit (99243) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available that can render these 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an oncology office visit (99243) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary following the elective surgery. The Plan denied your request. The Plan says the criteria for coverage of inpatient care have not been met.

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 pre-approve 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 patient is a 72-year-old male who is requesting admission to an acute care hospital following an elective/planned right shoulder arthroplasty procedure. The records do not show that the patient has significant health factors that would lengthen the post-operative care and there are no complications noted as related to the procedure. The records do no suggest that the patient would require hospital care that would cross 2 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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a second opinion. You say that you would like a second opinion. The Plan denied your request. The Plan says there are in-network providers available for these 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 a second opinion to be provided by an out-of-network (OON) provider.