Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity prosthesis.
You asked the Plan to pre-approve a powered prosthesis. The Plan denied your request. The Plan says this 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 a powered prosthesis. Our reviewer says that the requested powered prosthesis is not considered medically reasonable and necessary in this case. Our physician reviewer found that the records do not show why a standard prosthesis cannot be used by 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 a powered prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity prosthesis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you need this because
you are unable to walk. The Plan denied your request. The Plan says you have not had an MRI in the last 30
days.
The Plan must follow Medicare rules. Medicare rules say that percutaneous vertebral augmentation when there
is acute or subacute osteoporotic VCF (T5 - L5) confirmed by recent (within 30 days) advanced imaging
demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT.
We looked at the file and Medicare rules. The records do not show that you have had an MRI or bonescan/
SPECT/CT within the previous 30 days. The record shows that your most recent MRI was on March 30,
2020. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral
augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve
percutaneous vertebral augmentation (22514).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta.
You asked the Plan to pre-approve Tradjenta. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tradjenta.
Benefits for Tradjenta 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair articulating leg rests (E1012).
You asked the Plan to pre-approve the articulating leg rests. You say that the feature is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that articulating leg rests are covered when 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 the articulating leg rests. Our reviewer says that the requested articulating elevated leg rests are not medically necessary. Our physician reviewer found there is no documentation of a high risk for pressure ulcers, need for intermittent catheterization for bladder management, or of increased tone or spasticity. 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 articulating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair articulating leg rests (E1012).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from February 1, 2020 through February 27, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received SNF care from February 1, 2020 through February 27, 2020, which is 26 days. Therefore, days 1-20 of your SNF care you pay a $20 copayment per day and the total is $400. Furthermore, days 21-26 of your SNF care you pay a $80 copayment per day and the total is $480. Your total cost-share responsibility is a $880 copayment. 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 SNF care from February 1, 2020 through February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for acute-on-chronic respiratory failure. The enrollee has received antibiotics, breathing treatments steroids and supplemental oxygen. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and nebulizer, with compressor (E0570) provided on January 8, 2020 and February 12, 2020. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  
 
Review of the file show that you received an oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and nebulizer, with compressor (E0570) provided on January 8, 2020 and February 12, 2020. You are asked to pay 20% coinsurance for the DME. 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 oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) and nebulizer, with compressor (E0570) provided on January 8, 2020 and February 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc. 
 
You asked the Plan to pre-approve GenVisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve GenVisc. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of bilateral primary osteoarthritis of the knee. The provided documentation does document failed trials of other therapies including non-steroidal anti-inflammatory agents and steroid injection of the knee. The documentation does not document that the enrollee has had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. The documentation does not support that the required drugs would be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GenVisc have not been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the observation stay, the CT scan, and the
specialist office visit provided from March 12, 2020 to March 14, 2020.
You asked the Plan to reduce the copayments for the observation stay, the CT scan, and the specialist office
visit. You say that you feel this was an inpatient stay and you should only be responsible for the inpatient
hospital 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 $250
copayment for outpatient hospital observation services, a $275 copayment for each advanced imaging service
(e.g., MRI, CT and PET scans, nuclear medicine, and stress tests), and a $35 copayment for each specialist
visit, including outpatient clinic visits.
You have been asked to pay a $250 copayment for the observation stay. You have been asked to pay a $197.41
copayment for the CT scan, which is less than the standard amount, and a $35 copayment for the specialist
office visit. The observation stay and the CT scan fall within the "Outpatient hospital observation" benefit
category. The specialist office visit falls within the "Outpatient hospital services" benefit category. The medical
record shows you were placed in observation status.
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 reduce the copayments for the observation stay, the CT scan, and the specialist office
visit provided from March 12, 2020 to March 14, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformoterol (Brovana).
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Perforomist.
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 Brovana. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease. The Plan requires a trial of Perforomist before they will approve the requested drug. The documentation does not indicate the enrollee has tried and failed the required drugs. The documentation does not support that Perforomist would likely be less effective, 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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol (Brovana).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there's no benefit for out-of-network coverage unless the services are urgent or cannot be provided in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve endovenous services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Maxx Performance Spoke (Rear Wheel Type) and quick release axle.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that these are non-medical features.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Maxx Performance Spoke (Rear Wheel Type) and quick release axle.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroplasty services (CPT 23472-22) provided to the enrollee on September 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says modifier 22 is denied.
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 23472 is "arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))." 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 services at issue in this case were not coded correctly. Our coding reviewer found the 22 modifier appended to Current Procedural Terminology (CPT) 23472 does not meet criteria for reimbursement consideration. The medical records provided states "due to the patient's body mass index of 38.4, a more detailed and complex surgical dissections was required. This was carried out superficially and then throughout the remainder of the case. Therefore, the 22 modifier has been utilized." However, excess BMI alone, is not justification for the use of Modifier 22. There is no other detail in the operative not to identify increased procedural services of at least 50%, therefore Modifier 22 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for arthroplasty services (CPT 23472-22) provided to the enrollee on September 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Magnetic Resonance Imaging (MRI) of
the lower extremities (73721, 73718) provided February 7 to February 8, 2020.
You asked the Plan to waive the copayments for the MRI's. You say that the copayments should be waived The
Plan denied your request. The Plan says the correct cost-sharing was applied.
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 Diagnostic Tests.
You have been asked to pay two $40 copayments for the MRI's. The MRI's fall within the 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 copayments for Magnetic Resonance Imaging
(MRI) of the lower extremities (73721, 73718) provided February 7 to February 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET with concurrently acquired CT (78815) provided on January 14, 2020.
You asked the Plan to pay for the PET. You say that you would like reconsideration because this service was performed at the request of the referring doctor and was medically necessary. The Plan denied your request. The Plan says diagnosis code C50.911 is not listed as an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 78815 is not supported in the record. Specifically, per the Medicare Claims Processing Manual diagnosis code C50.911 is not listed as an appropriate diagnosis for the billed PET service. Based on this information, we decided that Medicare rules for coverage of the PET have not been met. Therefore, we decided that the Plan does not have to pay for PET with concurrently acquired CT (78815) provided on January 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this request exceeds your needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two (2) fillings (D2330 and D2331) provided on February 25, 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.
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. You exhausted your benefit because you had a total of four (4) fillings on February 25, 2020. The Plan paid for two (2) of the fillings. Your EOC states, Restorations (Fillings) - Amalgam and/or Composite - Frequency/Limitations - Two (2) procedures per calendar year. Therefore, you are responsible for the cost of the other two (2) fillings. Therefore, we decided that the Plan does not have to pay for two (2) fillings (D2330 and D2331) provided on February 25, 2020.