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

We decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says it's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found step therapy, as outlined by the plan, requires Orthovisc and Monovisc be trialed first. Documentation supports the enrollee had elevated blood glucose levels following Orthovisc injection. The documentation does outline contraindications or reasons why Monovisc is not considered. Without the support of the documentation, Euflexxa is not approved as step criteria is not 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental cleaning (D1110), periodic oral evaluation - established patient (D0120) and bitewings - two radiographic images (D0272) provided on February 12, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency 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 adult dental cleaning and checkup examination are services that are allowed one time every twelve months. The 2 x-rays for decay is a service that is allowed one time every twenty-four (24) months. The records show that you received an adult dental cleaning and checkup examination less than twelve months ago on June 13, 2019. The records show that you received 2 x-rays for decay less than twenty four months ago on May 24, 2018. Therefore, we decided that the Plan does not have to pay for dental cleaning (D1110), periodic oral evaluation - established patient (D0120) and bitewings - two radiographic images (D0272) provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of a non-invasive vagus nerve stimulator device.
You asked the Plan to pre-approve surgical placement of a non-invasive vagus nerve stimulator device. You say that a non-invasive vagus nerve stimulator device is necessary for the enrollee's condition. The Plan denied your request. The Plan says a non-invasive vagus nerve stimulator device is not reasonable and 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 surgical placement of a non-invasive vagus nerve stimulator device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review the records provided, utilizing CMS CAG-00313R Vagal Nerve Stimulator device which specifically states that CMS has determined that there is a sufficient evidence to conclude that Vagal Nerve Stimulation is not reasonable necessary for treatment of resistant depression. Based on the information provided use of legal nerve stimulation is not considered reasonable and medically necessary based on the stance by CMS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical placement of a non-invasive vagus nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical placement of a non-invasive vagus nerve stimulator device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX 25mg/2.5ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says it's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drugs. The documentation does not support that Orthovisc and Monovisc 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX 25mg/2.5ml syringe for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from August 27, 2019 through November 7, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of 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. Review of the file show that you exhausted your $500 benefit allowance. Therefore, we decided that the Plan does not have to pay for the dental services provided from August 27, 2019 through November 7, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 28, 2019.You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) (D6066) and custom fabricated abutment -includes placement (D6057) provided on January 29, 2020.You asked the Plan to pay for the dental services. You say that you called the customer service department and were told that her dental plan was going to pay 50% on D6066 and 50% on D6057.The Plan denied your request. The Plan says they confirmed you did not contact the customer service department prior to receiving service to verify your benefit information. The Plan states you did not call the customer service department regarding your benefits after the date of service and any information given to you during the call was not a factor in you having the service done.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay for implant supported porcelain fused to metal crown (titanium, titanium alloy,high noble metal) (D6066) and custom fabricated abutment -includes placement (D6057) provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing examination provided on January 25, 2020.
You asked the Plan to waive the copayment for hearing exam. You say that you should not have 2 copayments for the same visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment for in-network hearing exam. This hearing exam is separate from a standard office visit charge; therefore, a separate hearing examination copayment applies. You have been asked to pay $10 copayment for hearing exam. Hearing exam falls within the Hearing Services 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 a hearing examination provided on January 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures.
You asked the Plan to pre-approve the dentures. You say that you cannot eat without your dental plate. The Plan denied your request. The Plan says services not covered by Medicare: Routine dental care, such as cleanings, fillings or dentures.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your EOC states that dentures are excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve dentures.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 64788 provided on October 18, 2019.You asked the Plan to pay for CPT code 64788. You say that the medical records support the billing of CPT code 64788.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 64788.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 64788 is Excision of neurofibroma or neurolemmoma; cutaneous nerve.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 CPT code 64788. Our reviewer says that the medical records do not support the billing of CPT code 64788. Our physician reviewer found based on the documentation provided, the enrollee was referred by her PCP to a surgeon for two lesions, which were presumed to be lipomas. The lesions were surgically removed. The operative report notes that the lesions were small and subcutaneous. There is no description of the lesions being attached to or near nerves. No pathology reports have been submitted for review. While two lesions were removed, there is insufficient evidence to show that the lesions were neurofibromas or neurolemmomas. As such, the billing of CPT 64788 is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 64788 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 64788 provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Genvisc 850 injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a trial and failure of Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Genvisc 850 injection is not approved as step criteria is not 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Genvisc 850 injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says it's preferred viscosupplements are Orthovisc and Monovisc, and don't require prior authorization.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested drug does not meet the step therapy requirements. Our physician reviewer found there is no evidence of a trial and failure of the required drugs - Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 90834 and G0515 provided on October 30, 2019.
You asked the Plan to pay for CPT codes 90834 and G0515. You say that the medical records support the billing of CPT codes 90834 and G0515. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 90834 and G0515.
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 90834 is Psychotherapy, 45 minutes with patient. The CPT Code Manual definition of code G0515 is Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes. 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 CPT codes 90834 and G0515. Our reviewer says that the medical records do not support the billing of CPT codes 90834 and G0515. Our physician reviewer found the provider is requesting payment of psychotherapy provided on October 30, 2019. This enrollee is being treated for Major Depressive Disorder, Single Episode in Full Remission and Other Specified Anxiety Disorder. Based on review of the records provided, it is agreed that the documentation does not show the cognitive skills improvement. Based on review of the records provided this documentation does not substantiate the coding of a 90834 or a G0515 as there is no clear documentation of therapy or cognitive skills improvement.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 90834 and G0515 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 90834 and G0515 provided on October 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and manual therapy services (97140) provided by a chiropractor from July 17, 2019 through August 22, 2019.
You asked the Plan to pay for the chiropractic services. You say that your physician referred you for these services. The Plan denied your request. The Plan says the only services covered from a chiropractor are manual manipulation of the spine to correct subluxation. Any other services performed by a chiropractor are not covered are per Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99203) and manual therapy services (97140) provided by a chiropractor from July 17, 2019 through August 22, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on May 13, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You were referred for the laboratory services.This provider is a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on May 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you at a foreign hospital from March 26, 2019 to September 20, 2019.
You asked the Plan to pay for these services. You say that you were told you would have coverage while traveling. The Plan denied your request. The Plan says the services were not an emergency and are not covered.
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services furnished outside of the United States. The Plan contract says that you are covered for emergency care world-wide. We looked at the file and Medicare rules. The file shows that you received services at a hospital outside of the United States. The file does not support that the services were for an emergency condition. Based on this information, we found that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to you at a foreign hospital from March 26, 2019 to September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy encourages a trial of zoledronic acid, which is just as effective.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that Our physician reviewer found the provided medical records do not indicate a trial and failure of zoledronic acid. The provided medical records do not indicate that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 18, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were seen for less than five minutes for a follow-up appointment. You say the receptionist told you that you did not have a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each office visit to other providers. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were evaluated during the office visit. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to previous procedures.
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 the specialist office visit provided on December 18, 2019.