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

We decided that the Plan does not have to pre-approve 9 more months of home ventilator, any type, used with non-invasive interface.
You asked the Plan to pre-approve 9 more months of home ventilator, any type, used with non-invasive interface. You say that the home ventilator is medically necessary. The Plan denied your request. The Plan says they will approve 3 months of the ventilator but 9 more months of a home ventilator is not medically necessary
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 9 more months of home ventilator, any type, used with non-invasive interface. Our reviewer says that the service is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. There is no documentation of failure of BiPAP. There is no documentation of increased pCO2 while in a stable state. The enrollee has apparently been provided with a home ventilator, but there are no data on usage. Even if the enrollee does have hypercarbia, the medical records suggest that BiPAP would be sufficient to meet the enrollee's needs. A home ventilator is considered not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 more months of home ventilator, any type, used with non-invasive interface have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 more months of home ventilator, any type, used with non-invasive interface.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benzonatate capsules.
You asked the Plan to pre-approve the Benzonatate capsules. You say that the enrollee has tried and failed two rounds of antibiotics. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Benzonatate capsules.
Benefits for the Benzonatate capsules 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98941, 99201) provided from January 9, 2020 to January 16, 2020.
You asked the Plan to pay for chiropractic services. You say that it was medically necessary for the enrollee to receive these services from an out-of-network provider. The Plan denied your request. The Plan says coverage of these services is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for chiropractic services (98941, 99201) provided from January 9, 2020 to January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 28, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you called the Plan and were advised the provider was in-network. The Plan denied your request. The Plan says they verified that you were never advised by the supplemental dental plan or your medical plan that the provider was in-network.
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 shows that you received services from an out-of-network provider. Services provided by an out-of-network or non-contracted provider are not provided under this benefit program. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 28, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve Tecentriq. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the use of this drug is considered off-label.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Tecentriq. Our reviewer says that use of this drug is not supported. The requested use of Tecentriq is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick.
You asked the Plan to pre-approve Enbrel SureClick. You say that this drug has been effective for the enrollee. The Plan denied your request. The Plan says this drug does not fall under the enrollee's Part B 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. This drug is on the Self-Administered Drug Exclusion List (A52800). Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick.
Benefits for Enbrel SureClick 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: 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 guidelines were not followed.
The Plan must follow Medicare rules. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each (A4414) and ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each (A4425) provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 DME have not been met. The services are included in the Part A skilled nursing facility (SNF) payment per Medicare guidelines as the member was in a covered Part A stay during the date of service. Therefore, we decided that the Plan does not have to pay for ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each (A4414) and ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each (A4425) provided to the enrollee on January 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 6, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the Plan failed to notify you of the in-network requirement for covered dental services. The Plan denied your request. The Plan says you do not have out-of-network 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. The provider is not in-network and your EOC clearly states, out-of-network dental services are not a covered benefit. You must use a supplemental in-network dentist to obtain these supplemental dental benefits. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 6, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of the plan preferred drug zoledronic acid is required before alternatives can be considered.
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 Prolia. Our reviewer says that rules for coverage were not met. Our physician reviewer found there was no trial of the plan preferred drug, zoledronic acid, and the record did not show any reason why it would be unsafe or ineffective for this 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (D9222 and D9223) provided on February 11, 2020.You asked the Plan to pay forthe anesthesia services. You say that you would like reconsideration because the anesthesia was medically necessary.The Plan denied your request. The Plan says the anesthesia was provided per the member's request and was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the anesthesia services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member's medical history did not indicate any condition that would meet the criteria for coverage for general anesthesia for the extractions.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 anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay foranesthesia services (D9222 and D9223) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450) and limited oral evaluation - problem focused (D0140) provided on October 11, 2019.
You asked the Plan to pay for the dental services. You say that this was for a removal of what turned out to be a non-cancerous growth on the roof of your mouth. You state this was not a dental procedure. The Plan denied your request. The Plan says the services are not covered under Medicare or the Health Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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. There was no evidence of illness or injury to the mouth and no evidence of future radiation treatments. Therefore, we decided that the Plan does not have to pay for removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450) and limited oral evaluation - problem focused (D0140) provided on October 11, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 76857 provided on December 10, 2019.
You asked the Plan to pay for CPT code 76857. You say that the medical records support the billing of CPT code 76857. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 76857.
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 76857 is Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles). 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 76857. Our reviewer says that the medical records do not support the billing of CPT code 76857. Our physician reviewer found this is a male with prostate cancer that was seen in the office 12/10/19. The note states a bladder scan was performed with postvoid residual of 0.0 mL. The procedure was coded as 76857. While the bladder was scanned for a postvoid residual, there is no description of the bladder or documented ultrasound report interpretation or images. The documentation does not support the billing of CPT code 76857. 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 76857 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 76857 provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is subject to step therapy.
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 injection is not medically reasonable or necessary. Our physician reviewer found the prescriber stated
that the enrollee has not had either Monovisc or Orthovisc because the copayments are too high. The provider
has not indicated that Orthovisc and Monovisc would not be as effective for the member or would have adverse
effects.
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.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on January 12, 2020.
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says when multiple medical visits occur on the same day in the same revenue center, providers must bill the claim with Condition Code G0. The file shows that Condition Code G0 was not added to the claim for the second emergency room visit. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), drugs or medicaments dispensed in the office for home use (D9630), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on January 28, 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 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. 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 periodontal maintenance (D4910), drugs or medicaments dispensed in the office for home use (D9630), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 99291 provided on October 16, 2019.You asked the Plan to pay forCPT code 99291. You say that youwould like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The PT/PC indicator for CPT code 99291 is "0" = Physician service codes. This indicator identifies codes that describe physician services. Examples include visits, consultations, and surgical procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 & TC cannot be used with these codes. The total Relative Value Units (RVUs) include values for physician work, practice expense and malpractice expense. There are some codes with no work RVUs. Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of "0" indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. The XE modifier shall only be used to describe separate encounters on the same date of service and a modifier indicator of "0" indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. In this case, CPT code 99291 has a modifier indicator of "0."Therefore, we decided that thePlan does not have to pay forCPT code 99291 provided on October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary. The Plan denied your request. The Plan says a trial of Retacrit is required before alternatives like Procrit can be considered.
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 Procrit. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the record does not show a trial of the plan preferred drug or any reason why it would be contraindicated for this 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
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 guidelines were not followed.
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 the provided medical records do not indicate that the patient has tried and failed the required drug. 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.