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

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Durolane. Our reviewer says that Durolane is not approved as step criteria have not been met. Our physician reviewer found this appeal considers the request for Durolane for the treatment of osteoarthritis of the left knee. Our reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our physician reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting, such as skilled nursing facility, outpatient setting or home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis, a urinary tract infection, and acute kidney injury. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MyoPro Motion G Orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke and has left hemiparesis. The provided medical records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested services for the enrollee's specific clinical situation. Therefore, the enrollee does not meet criteria for the requested item.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120),
bitewing radiographic images (D0274), and periodontal maintenance (D4910) provided on March 15, 2021.
You asked the Plan to pay an additional amount for a periodic oral evaluation, bitewing radiographic images,
and periodontal maintenance. You say that you were not aware that the provider was out-of-network. The Plan
denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional
payment can be made.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, bitewing radiographic images, and periodontal maintenance have not
been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the
plan. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral
evaluation (D0120), bitewing radiographic images (D0274), and periodontal maintenance (D4910) provided on
March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 2 therapeutic CGM and sensors (CPT code(s): K0553, K0554), for the enrollee.
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The enrollee tests their blood glucose twice a day and take a long-acting insulin once a day. The enrollee does not adjust an insulin dose based on their blood glucose results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 therapeutic CGM and sensors (CPT code(s): K0553, K0554), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2021, by a non-plan provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-plan 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. The requested provider in this case is not a network provider with the Plan. The referring provider 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 the genetic testing provided on March 17, 2021, by a non-plan provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 88365 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 88365 (in-situ hybridization) and 88377 (morphometric
analysis). Code 88365 is a column II code with a modifier indicator of 1 when billed with column I code
88377. Code 88365 was not billed with an appropriate modifier to allow for separate payment. Given that
primary procedure code 88365 is not covered, add-on code 88364 is also not covered. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for magnetic resonance imaging (MRI) provided on September 25, 2020.
You asked the Plan to pay for MRI. You say that this imaging was for arthritis that is unrelated to your
worker's compensation injury. The Plan denied your request. The Plan says that the denial of payment for this
service is correct, because this Plan is the secondary payer and your primary coverage is through your worker's
compensation settlement.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has not provided any evidence to support that the Plan has met its obligation with regards to
coordination of benefits. Therefore, we decided that the Plan has to pay for magnetic resonance imaging (MRI)
provided on September 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 13, 2021 to February 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were billed incorrectly.
The Plan must follow Medicare rules.The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 pay for the home health services rendered from February 13, 2021 to February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675, E0673) provided on February 18, 2021.
You asked the Plan to pay for an intermittent limb compression device. You say that the item at issue was a medical necessity for you. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for deep vein thrombosis (DVT).
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that you had lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675, E0673) provided on February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (CPT code 93306), for the enrollee.
You asked the Plan to pre-approve the service. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the same study was approved and completed on April 23, 2021. The Plan states repeat imaging less than three (3) months later is not supported by medical necessity criteria.
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 service. Our physician reviewer found the record indicates that the enrollee had the same test approved and completed in April 2021. At the time the enrollee, who has diabetes and aortic stenosis underwent an echocardiogram that revealed an aortic gradient of 58/37 and a valve area of 1.1 cm2. The requested service is requested as part of a research study. Stress test demonstrated a reversible defect but cardiac catherization demonstrated normal coronary arteries with a right dominant system. Severe aortic stenosis was found and TAVR recommended. The enrollee is undergoing evaluation for TAVR. The medical records provided do not establish the medical necessity and reasonableness of the requested study as defined by Medicare rules. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (CPT code 93306), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on
March 30, 2021.
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that there was an
abnormality on your mammogram screening so you needed the ultrasound and thought that it would be covered
as part of the screening. 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 $35
copayment for outpatient diagnostic tests.
You had an ultrasound of the breast on March 30, 2021. An ultrasound of the breast is not included in a
mammogram screening and is considered diagnostic. Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment for an ultrasound of the breast. An ultrasound of the breast falls
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for an ultrasound of the breast provided on March 30, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that this procedure is medically reasonable and
necessary. The Plan denied your request. The Plan says that the denial of authorization for this service is
correct, because CardioMEMS is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has severe heart failure with persistent Class III symptoms and is on appropriate
guideline-directed congestive heart failure (CHF) medications with a reported recent hospitalization for CHF as
well. Management of his condition with standard medical therapy and relying on signs and symptoms has not
been effective in keeping him with minimal symptoms and has resulted in acute hospitalization. CardioMEMS
device monitoring in this situation can provide additional heart filling pressure data to better manage very
complex diuretic and vasodilator regimens. Data from a trial along with longer term follow-up studies has
shown a significant decrease in hospitalizations and improvement in heart failure symptoms with the use of this
device. There is also published expert opinion in the cardiology literature as to its appropriate use as well as
reasonable patient selection criteria and approved indications, all of which are met in this clinical instance. It
would therefore not be considered investigational and would meet medical reasonableness and necessity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to preapprove
the CardioMEMS procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on November 16, 2020.
You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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 drug test have not been met.
CPT code G0483 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on November 16, 2020, and received by the lab on November 17, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture-maxillary (CPT code D5110) and complete denture-mandibular (CPT code D5120).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. 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. Therefore, we decided that the Plan does not have to pre-approve complete denture-maxillary (CPT code D5110) and complete denture-mandibular (CPT code D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92014) and progressive lenses (V2781) provided on April 28, 2021.
You asked the Plan to pay for an eye exam and progressive lenses. You say that your vision was getting blurred since your last visit in November 2020. You also say that you could not wait till November 2021 for your yearly eye exam. The Plan denied your request. The Plan says you had a routine eye exam less than a year ago, therefore, the benefit was exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye exam a year as well as a $100 allowance towards the purchase of eyewear, including standard lenses, frames and contact lenses. We looked at the file and the Plan's rules. The records show you had a routine eye exam on November 4, 2020. The Plan contract confirms you are eligible for one routine eye exam a year; therefore, you have exhausted the benefit for an eye exam. The progressive lenses which you purchased are not covered benefits of the Plan. The record indicates that the Plan has paid for the standard lenses and frames, you are responsible for the difference between the cost of the standard lenses and progressive lenses. Based on this information, we decided that the Plan's rules for coverage of an eye exam and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92014) and progressive lenses (V2781) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Apple Watch provided on April 1, 2021.
You asked the Plan to pay for the Apple Watch. You say that the Apple Watch has an electrocardiogram (EKG) feature that Fitbit does not have. You say that you have a history of heart condition. You also say that you feel that the Apple Watch should be covered instead. The Plan denied your request. The Plan says the Apple Watch is excluded from coverage under the Wallet Benefit.
Medicare generally does not cover fitness trackers. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the rules in the Evidence of Coverage have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Apple Watch have not been met. Specifically, the Evidence of Coverage clearly states that Apple Watch is excluded from coverage under this benefit. Therefore, we decided that the Plan does not have to pay for the Apple Watch provided on April 1, 2021.