Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthoses provided on June 6, 2019.
You asked the Plan to pay for the ankle-foot orthoses (L1971). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthoses have not been 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 ankle-foot orthoses (L1971). Our physician reviewer found based on the documentation provided the health plan's denial should be upheld. There is no evidence that the enrollee has weakness or deformity of the feet or ankles. There is no evidence that the enrollee requires stabilization of feet or ankles. As such, the provided orthoses are not shown to have been medically necessary or reasonable. 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 ankle-foot orthoses (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle-foot orthoses provided on June 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve the Botox injections. You say that Botox injections are medically necessary for treatment of the enrollee's gastroparesis, nausea, and vomiting. The Plan denied your request. The Plan says the peer reviewed literature does not support the clinical value and effectiveness of the requested drug for the enrollee's indications.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Botox injections. Our reviewer says that the use of Botox for the treatment of the enrollee's gastroparesis, nausea, and vomiting is not medically accepted as a safe, effective, and appropriate use of the 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 the Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on May 20, 2019 by out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that medically necessary services were provided at the request of the medical director. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications including deterioration, amputation, infection and or hospitalization. You also say that emergency wound care was provided in the absence of another contracted / available wound care physician. The Plan denied your request. The Plan says the health plan and Medicare rules require the member to obtain covered services from plan providers except for emergency care and out-of-area urgent care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on May 20, 2019 by out of network provider.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 12/21/19 with status epilepticus. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with ventilator management, surveillance laboratory studies, wound care, hemodialysis, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve self-administered Procrit (epoetin alfa).
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee needs to continue therapy with this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B when a pharmacy dispenses the drug directly to the enrollee for self-administration or to be taken to a provider. The Plan also says that this drug has been approved under the enrollee's Medicare Part D prescription drug benefits.
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 self-administered Procrit (epoetin alfa).
Benefits for self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer (14301 and 14302) provided on April 18, 2019.
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records did not include documentation of an adjacent tissue transfer or rearrangement of any area; defect 30.1sq cm to 60.0sq cm
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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq. cm to 60.0 sq. cm. The CPT code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq. cm, or part thereof (List separately in addition to code for primary procedure). We asked our coder 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 adjacent tissue transfer. Our reviewer says that 14301 does not meet criteria for billing or reimbursement consideration. The medical record does not document a secondary incision being made or surgically created defect. Therefore, there is not enough information in the
operative note to verify an adjacent tissue transfer or rearrangement, any area; defect 30.1 sq. cm to 60.0 sq. cm was performed. Our reviewer found 14302 does not meet criteria for billing or reimbursement consideration. CPT code 14302 is an add-on code and requires the associated primary code to be eligible for reimbursement. In this case, the primary CPT code 14301 is not eligible for reimbursement, thus, making CPT 14302 ineligible for reimbursement as well. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for adjacent tissue transfer (14301 and 14302) provided on April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on February 5,
2019.
You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says documentation submitted did not
include documentation of needle electromyography; 2 extremities with or without related paraspinal areas
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 95861 is needle electromyography; 2 extremities with or
without related paraspinal areas.
We asked our coder 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 needle electromyography. Our reviewer says that 95861
does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records
provided does not have documentation of a Needle electromyography 2 extremities with or without related
paraspinal areas being performed on February 5, 2019, therefore the service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the needle electromyography have not been met. Therefore, we decided that the
Plan does not have to pay for needle electromyography (95861) provided on February 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 15, 2019 to August 19, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges and cannot afford 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 a $275 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from August 15, 2019 to August 19, 2019. Therefore, you are responsible to pay a $275 copayment for days 1-4 (August 15, 2019 to August 18. 2019). $275 (copayment) x 4 (inpatient days) = $1,100.00. You have been asked to pay the total copayment amount of $1,100.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from August 15, 2019 to August 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on June 21, 2019.
You asked the Plan to pay for the air ambulance services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the enrollee was not taken to the nearest appropriate facility.
The Plan follows Medicare rules. The rules say that Medicare does not pay for transport because the patient or
the patient's family prefers a specific hospital.
We looked at the file and Medicare rules. The record shows the family desired the enrollee to be transported to
a specific facility. Based on this information, we decided that Medicare rules for coverage of the air
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services
provided on June 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a SNF stay from April 10, 2018 to April 30, 2018.
You asked the Plan to waive the coinsurance for a SNF stay. You say that you were told that the services would be covered 100% and were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 30% coinsurance for out-of-network SNF care. The enrollee had a SNF stay with an out-of-network provider from April 10, 2018 to April 30, 2018. Therefore, the out-of-network cost-sharing charges were applied correctly. The total allowed amount is $10,897.20 and 30% of that is $3,269.16. The enrollee has been asked to pay the total coinsurance amount of $3,269.16 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a SNF stay from April 10, 2018 to April 30, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on July 11, 2019 by out of network provider.
You asked the Plan to pay for a domiciliary or rest home visit for the evaluation and management of an established patient. You say that this claim is denied for no authorization. You say that there was a prior authorization/gap exception number listed. You also say that authorization was approved for date of service May 24, 2019 through August 22, 2019 and the authorization. The Plan denied your request. The Plan says the authorization was cancelled as the provider called and stated that the case will be cancelled and will need to be resubmitted under behavioral health. The Plan says that the practitioner is a non-network provider who does not work with the member's health plan, and the member self-directed for services. No prior authorization for any services was noted. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The record does not contain documentation to show that the Plan pre-approved the services 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 a domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on July 11, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower partial dentures.
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 request exceeds the benefit limit.
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. The Plan covers these services
once every 60 months.
Review of the file shows that you received upper and lower partial dentures on June 20, 2017 for which the
Plan approved and paid. You are not eligible for these services until June 28, 2022. Based on this information,
we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pre-approve upper and lower partial dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for eyeglasses provided on February 16, 2019.
You asked the Plan for additional reimbursement the eyeglasses. You say that the Plan told you that the provider was in-network. The Plan denied your request. The Plan says the reimbursement paid appropriately according to your benefits.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that you must receive routine vision services from a contracted provider. The file shows that the Plan reimbursed you according to your out-of-network routine eyewear benefit. Therefore, we decided that the Plan does not have to provide additional reimbursement for eyeglasses provided on February 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humulin N 100 Unit/ML vial.
You asked the Plan to pre-approve Humulin N. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Humulin N is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humulin N 100 Unit/ML vial.
Benefits for Humulin N may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo (J3590).
You asked the Plan to pre-approve Ziextenzo (J3590). You say that the requested Ziextenzo is medically necessary. The Plan denied your request. The Plan says the requested Ziextenzo 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 Ziextenzo (J3590). Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of Follicular lymphoma grade I, lymph nodes of head, face, and neck. The enrollee has recurrent non- Hodgkin lymphoma. He is to be enrolled in a TG therapeutics trial. The Plan requires a trial of two of the following: Neulasta, Fulphili, or Udenyca, before they will approve the requested drug, Ziextenzo. The documentation shows that the enrollee has not tried and failed any of the required drugs. The documentation does not support that Neulasta, Fulphili, or Udenyca would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ziextenzo (J3590) have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo (J3590).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) provided on August 13, 2019 by an out of
network provider.
You asked the Plan to pay for an eye exam. You say that the enrollee was in a nursing home setting at the time
services were rendered. You say that the patient couldn't choose an in-network optometrist as they do not
provide services in the patient's place of residence. You say that since they have an exclusive contract with the
facility, the doctors with the out-of-network provider are the only providers who will treat the patients for
optometry care. You further say that you had no prior knowledge of which patients you would be required to
see and must provide service to all of them. You also say that most patients require urgent care and it is not
possible to request authorization before services are rendered, and due to the disability, the patient could not
visit an in-network provider. The Plan denied your request. The Plan says services were denied due to services
provided by a non-participating provider. The Plan also says that there are only three exceptions to receiving
care from an out-of-network provider: emergency care, prior authorization or kidney dialysis 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue.
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that
the Plan does not have to pay for an eye exam (92004) provided on August 13, 2019 by an out of network
provider.