Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital for altered mental status and hypotension. The enrollee remains hypotensive and on vasopressors. The enrollee is not intubated/ventilated. 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. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that thePlandoes not have to pre-approveFluorouracil cream.You asked the Planto pre-approveFluorouracil cream. You say that this is medically necessary due to the enrollee's history of skin cancer.The Plandenied your request. The Plansays coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.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-approveFluorouracil cream.Benefits for Fluorouracil creammay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not have to pay fornatriuretic peptide testing (83880) provided on August 19, 2019.You asked the Planto pay fornatriuretic peptide testing. You say that this should be covered.The Plandenied your request. The Plansays this was 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 pay for natriuretic peptide testing. Our reviewer says that this was not medically necessary.Our physician reviewer found the submitteddocumentation shows that the enrollee had several resulted tests for Natriuretic peptide testing over consecutive months.These results were within laboratory normal range. The enrollee did not report new or different respiratory symptoms. Compendia do notsupport the use of this test for screening purposes. It is a diagnostic test that can be used in the evaluation and testing of congestive heart failure. The documentation does not support these tests were medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of natriuretic peptide testinghave not been met.Therefore, we decided that the Plandoes not have to pay fornatriuretic peptide testing (83880) provided on August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pay forco-surgeon services on a left carotid endarterectomy provided on May 2, 2019.Youasked the Planto pay forco-surgeon services. You say that two surgeons were required due to the complexity of the procedure.The Plandenied your request. The Plansays there is no evidence that the procedure or the enrollee's condition was complex in nature.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 pay forco-surgeon services. Our reviewer says that the documentation does not support the medical necessity to justify coverage of the co-surgeon. Our physician reviewer found the documentation did not demonstrate that the two surgeons each brought different skills to the table and that both were required for distinct portions of the procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of co-surgeon serviceshave not been met.Therefore, we decided that the Plandoes not have to pay forco-surgeon services on a left carotid endarterectomy provided on May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that your previous dentist made the upper denture wrong. You say that you need a new one. The Plan denied your request. The Plan says dentures are only covered once every 5 years. The Plan also says that the frequency limit for dentures has been reached.
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 and dentures are a covered service, the frequency limit has been reached. The record shows that you last received an upper denture on December 20, 2018 which the Plan paid for. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 29, 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. 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) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 8), the endosteal implants
(D6010 x 2), incision and drainage of abscess (D7510), localized delivery of antimicrobial agents (D4381 x 8),
and the bone replacement graft for ridge preservation (D7953 x 2) provided on September 30, 2019 by the out
of network provider.
You asked the Plan to pay for the dental services. You say that the 2 teeth removed for abscesses on 2 teeth.
You say that the services were an emergency. You say that you had the services out of network because the in
network providers would not provide the services without your gums being scraped. You say that the 2
abscessed teeth needed to be removed immediately and you had no time for gum scraping. You also say that
emergencies can be done by an out of network dentist. The Plan denied your request. The Plan says the
provider in this case is not a network provider. The Plan also says that services must be received from a
participating general dentist.
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 dental services you received are not
covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for
the surgical extractions (D7210 x 8), the endosteal implants (D6010 x 2), incision and drainage of abscess
(D7510), localized delivery of antimicrobial agents (D4381 x 8), and the bone replacement graft for ridge
preservation (D7953 x 2) provided on September 30, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvea power scooter. You say that a power scooter is preferred for doorways and elevators.The Plan denied your request. The Plan says you have a power wheelchair. The scooter would be duplicate equipment. The Plan stateswhile it is understood the power wheelchair is 8 years old, the issue is not due to malfunction of the wheelchair but for convenience in doorways and ease in elevators or the community.The Plan must follow Medicare rules. The rules say Medicare coversDME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a power wheelchair. This equipment serves the same purpose as a power scooter.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea root canal and a crown for tooth # 12.You asked the Plan to pre-approvethe dental services. You say that the services should be covered. You say that you needed these services because of an infection.The Plan denied your request. The Plan says root canals and crowns are not listed as covered services.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 root canal and crown for tooth # 12 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea root canal and a crown for tooth # 12.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for an eye exam provided on August 27, 2019.
You asked the Plan to waive the copayment for physician's services for an eye exam. The Plan denied your request. The Plan says the claim processed correctly.
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 $40 copayment for vision care, Medicare-covered exam. You have been asked to pay $35 copayment for physician's services for an eye exam. However, the physician's services for an eye exam falls within the vision care, Medicare-covered exam benefit category. 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 physician's services for an eye exam provided on August 27, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of hyaluronate (Supartz FX).
You asked the Plan to pre-approve Supartz FX. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc or Monovisc before it will approve use of Supartz FX.
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 Supartz FX. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Supartz FX. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc or Monovisc. The documentation does not support that Orthovisc or Monovisc would likely be less effective and/or likely 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 Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of hyaluronate (Supartz FX).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that the providers thought that you were having a stroke. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facility services and anesthesia services.
You asked the Plan to pre-approve the facility services and anesthesia services. You say that due to the enrollee's medical conditions and clotting disorder you are requesting that the facility and anesthesia services be covered. The Plan denied your request. The Plan says these services are dental and not a benefit of the enrollee's contract.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the facility services and anesthesia services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pay forphysician services provided to the enrollee on April 3, 2019 and billed under codes 64493-50, 64494-50 and 64495-50.You asked the Plan to pay forprocedure codes 64494-50 and 64495-50. We note the Plan approved code 64493-50.. You say that this claim should be paid.The Plan denied your request. The Plan says while code 64493-50 was approved, procedure codes 64494-50 and 64495-50 are not supported by the medical records in accordance with the Medicare billing guidelines.The Plan says that the paravertebral facet joints, also called zygapophyseal or "Z" joints, consist of the bony surfaces between the vertebrae that articulate with each other. The guidelines state the injection may be performed on a single level or on multiple levels. Physicians are to report 64493 for a single level, 64494 for a second level, and 64495 for the third and any additional levels. Physicians are to report 64494 and 64495 in addition to 64493. Physician are not to report 64495 more than once per day. This description was not documented in the medical records submitted. According to (CPT) code definitions and guidance, this case involves an inappropriate billing of (CPT) code 64495-50. (CPT) code 64495-50 is not supported in the documentation therefore is not payable as billed. 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 codes submitted do not support the services billed based on the Medicare billing requirements for codes 64494-50 and 64495-50. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on April 3, 2019 and billed under codes 64493-50, 64494-50 and 64495-50.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.You asked the Plan to pre-approvethe compression stockings. You say that you got a prescription for these and would like them to be covered.The Plan denied your request. The Plan says these stockings are non-covered under the surgical dressing benefit because they do  not meet the statutory definition  of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio (J3380).You asked the Plan to pre-approveEntyvio. You say that Stelarais more likely to cause an adverse reaction than Entyvio.The Plan denied your request. The Plan says that the enrollee has not tried Stelara as required by step therapy rules.Medicare covers Part B medications when they are reasonable and necessarybut 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 Entyvio. Our reviewer says that an exception to step therapy rules is medically necessary. Our physician reviewer found the Plan requires a trial of drug Remicade or Inflectra; and Stelara before they will approve the requested drug. However, it is documented that the enrollee tried Humira 8-10 in the past and did very well, but then got a bad rash after a year on the medication and had to discontinue it. The documentation shows that Entyvio was ordered because the Plan's required medications are more likely to cause adverse reactions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have been met.Therefore, we decided that the Plan has to pre-approveEntyvio (J3380)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 26, 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. 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 knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services rendered to you from September 16, 2019 to September 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider type is not covered.The Plan must follow Medicare rules. The rules say that a marriage family therapist is not eligible to participate in Medicare.The file shows that the provider at issue is licensed as a marriage family therapist (MFT).Therefore, we decided that the Plan does not have to pay forthe outpatient mental health services rendered to you from September 16, 2019 to September 23, 2019
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 September 13, 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. 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 knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 13, 2019.