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

We decided that the Plan does not have to pre-approve a Synvisc-One injection (J7325) in each knee, one time.

You asked the Plan to pre-approve the Synvisc-One injection. You say that you do not have a meniscus. You
say that this injection is to add some kind of cushion between your bones. You also say that you are trying to
prevent the need for a knee replacement. The Plan denied your request. The Plan says the requested medication
is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 the Synvisc-One injection. Our
reviewer says that the requested injection is not medically necessary. Our physician reviewer found the
provided documentation does not state that the enrollee has tried and failed the Plan's required 3 weeks of
conservative treatment, including non-surgical treatment such as physical therapy, pain medications, and failed
(did not improve from) joint aspiration and corticosteroid injection. The reviewer found that the
documentation does not support that Synvisc-One is medically reasonable or necessary for the enrollee. The
reviewer found that the documentation does not support that a Synvisc-One injection is safe and effective 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 Synvisc-One injection have not been met. Specifically, the file shows that
the enrollee has not tried and failed 3 weeks of conservative treatment. Therefore, we decided that the Plan
does not have to pre-approve a Synvisc-One injection (J7325) in each knee, one time.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after August 8, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met. d in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 94-year-old male with right humerus fracture, dysphagia, falls, and benign prostatic hyperplasia. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2) provided from April 6, 2021, through April 14, 2021.
You asked the Plan to pay for extractions. You say that you thought these services would be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extractions (D7210 x2) provided from April 6, 2021, through April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve a CGM. You say that these services are medically necessary. The Plan denied your request. The Plan says that the beneficiary is not insulin-treated.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who 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. looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower partial denture (D5214) provided on January 5, 2021.

You asked the Plan to pay for a lower partial denture. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a lower partial denture (D5214) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the bitewing x-rays (D0272) 
provided on April 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not receive a cleaning on December 15, 
2020. The Plan denied your request. The Plan says prophylaxis is covered once every 6 months. The Plan says 
that bitewing x-rays are covered once every 12 months. The Plan also says that the frequency limits for these 
services have been exceeded. 
 
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 the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for prophylaxis and bitewing x-
rays that you received on December 15, 2020, less than 6 months ago. Therefore, we decided that the Plan does 
not have to pay for the prophylaxis (D1110) and the bitewing x-rays (D0272) provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health visit provided on January 20, 2021
You asked the Plan to pay for the behavioral health visit. You say that you were never notified that telehealth visits were no longer a covered service. The Plan denied your request. The Plan says the service is not a covered benefit
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the behavioral health visit have not been met. This provider is a Doctor of Psychology. Psy-Ds are not eligible to enroll in Medicare, therefore this provider is not payable Therefore, we decided that the Plan does not have to pay for the behavioral health visit provided on January 20, 2021The Plan must follow Medicare rules. Medicare rules say a Doctor of Psychology is not eligible to enroll in the Medicare program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on April 15, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and a panoramic radiographic image. You say that you thought these services would be covered. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one every 36 months.
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 comprehensive oral evaluation, and a panoramic radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on April 7, 2021.
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on February 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on February 17, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97162, 97110, 97140) provided from June 26, 2020, to July 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.

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 97162 is "Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family". The CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". The CPT Code Manual definition of code 97140 is "Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes."

We asked our coding 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 services. Our reviewer says that the use of codes 97162, 97110, and 97140 is not supported by the records provided. Our coding reviewer found that June 26, 2020, the documentation did not include a PT evaluation: Moderate Complexity. In order to report code 97162, the documentation must include; history of present problem, examination of body systems, evolving clinical presentation, and clinical decision making of moderate complexity. For June 29, 2020, the documentation submitted did not show that Therapeutic exercises were provided. The Daily Note documents "see flow sheet for these procedures." No documentation was found to support these services were performed for this date of service. For July 3, 2020, the documentation submitted did not include CPT 97110 Therapeutic procedure or CPT 97140 Manual therapy techniques. The Daily Note documents "see flow sheet for these procedures." No documentation was found to support these services were performed for this date of service.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97162, 97110, 97140) provided from June 26, 2020, to July 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. The Superion spacer is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.

You asked the Plan to pre-approve the services. You say that you have been suffering from severe peripheral neuropathy for two years, and your doctor suggested acupuncture. The Plan denied your request. The Plan says this is only covered for low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this is not being requested for low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 21, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 68-year-old man with a family history of hypertension. The case file does not contain information demonstrating that the comprehensive cardiovascular genetic testing was medically reasonable and necessary 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the home sleep study provided on March 
11, 2021. 
 
You asked the Plan to waive the copayment for the home sleep study. You say that you were told by your 
Pulmonologist this would have no cost for you. The Plan denied your request. The Plan says they reprocessed 
the claim leaving you with the corrected $95 copayment. 
 
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 $95 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $95 copayment for the home sleep study. The home sleep study falls within the 
Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the home sleep study provided on March 11, 
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on May 13, 2021.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you didn't know the drug was so expensive and don't understand why you have to pay so much. You say that the fee you are paying should be reduced. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for Medicare covered Part B drugs and other Medicare covered items from a network provider. You have been asked to pay $250.20, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,251 ($1,251 x 20% = $250.20). The denosumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the denosumab injection provided on May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy and prolonged services rendered by an opt out provider on February 12, 2021.
You asked the Plan to pay for the psychotherapy and prolonged services. You say that you have been working with this provider since 2019 and you were given reimbursement until January 2021. You say that you were not given notice there was any status changes. The Plan denied your request. The Plan says payment cannot be issued for services rendered by a provider that has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy and prolonged services rendered by an opt out provider on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on January 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on January
28, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intrauterine device (IUD).

You asked the Plan to pre-approve IUD. You say that you are appealing with records. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. 

Medicare does not cover items/services for the purposes of preventing conception. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-approve an intrauterine device (IUD).