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

We decided that the Plan does not have to pre-approve Gel-One injections for the enrollee.
You asked the Plan to pre-approve the injections. 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 injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee has trialed Acetaminophen or intra-articular steroid injections of the knee. In addition, the enrollee has not trialed viscosupplemental treatments such as Synvisc or Sinvisc-One, and Euflexxa. Step therapy, as outlined by the plan, requires these be trialed first. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee resides in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission from 7/31/20 and forward.
You asked the Plan to pre-approve inpatient hospital admission from 7/31/20 and forward. You say that the
requested inpatient hospital admission from 7/31/20 and forward is medically necessary. The Plan denied your
request. The Plan says the requested inpatient hospital admission from 7/31/20 and forward 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 inpatient hospital admission from
7/31/20 and forward. Our reviewer says that the requested inpatient hospital admission from 7/31/20 and
forward is not medically necessary. Our physician reviewer found the enrollee presetned to the Emergency
Department on 7/29/2020 with concerns of lethary, vomiting and needing a higher level of care. Bacteriuria
was identified and she was treated for possible urinary tract infection but there were no signs of sepsis or
pyelonephritis. The stated plan was for discharge to rehab versus SNF. By 7/31/2020, she was medically stable
for discharge but there was not yet an identified receiving facility. The remainder of the hospital stay has been
custodial in nature. It is not medically reasonable and necessary for inpatient admission from 7/31/20 and
forward 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 inpatient hospital admission from 7/31/20 and forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission from 7/31/20 and
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that the enrollee wants to continue seeing this physician because he has been treating her since 2013 for a rare clotting disorder and she feels safe and comfortable sharing sensitive information with this physician. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator provided on March 13, 2020.
You asked the Plan to pay for oxygen concentrator. You say that it is unclear why this claim would be denied. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the documentation submitted does not include delivery confirmation documents to show that this item was supplied to the enrollee.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim. We looked at the file and Medicare rules. You did not submit documentation, such as proof of delivery, supporting that this item was provided to the beneficiary as billed on this claim. Without this information, you have not furnished sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the arthrocentesis provided from March 3, 2020 to March 17, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the arthrocentesis. You say that you do not believe you should have a copayment for the arthrocentesis (code 20610). 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the specialist office visit and a $32.56 copayment for each of the arthrocentesis procedures, which is less than the standard copayment amount. The specialist office visit and the arthrocentesis fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the arthrocentesis is considered a surgical service provided in a specialist office.
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 the specialist office visit and the arthrocentesis provided from March 3, 2020 to March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 30, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 27299 is 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 27299 is unlisted procedure, pelvis or hip joint. We find that CPT code 27299 is not supported in the medical record. Specifically, the operative report does not contain any documentation of an unlisted procedure on the pelvis or hip joint. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of the dental implants (D6010).
You asked the Plan to pre-approve the dental services. You say that you've had problems with your partial dentures either breaking or loosening which has created pain in your jaws making it difficult to chew and eat. This request is necessary for a better quality of life The Plan denied your request. The Plan says dental implants are not covered under the plan or Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of the dental implants (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthosis (L1686) provided on December 30, 2019.
You asked the Plan to pay for the hip orthosis. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not include
a physician order or proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case.
The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for hip orthosis (L1686) provided on December 30,
2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on February 27, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 21 for inpatient hospital but the enrollee was not admitted under inpatient status for the date of service in question. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of osteoporosis. She has not tried and failed the Plan's required drug of zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is 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-approveProlia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertical bitewings (D0277) provided on March 12, 2020.You asked the Plan to pay for the vertical bitewings. You say that your plan brochure shows that bitewing x-rays are covered every 12 months. You also say that there are no details stating the type of x-rays provided are not covered.The Plan denied your request. The Plan says this procedure is not a benefit under the dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the vertical bitewings (D0277) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on November 15, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says the record indicates that train of four monitoring was performed which does not meet the guidelines of CPT code 95999.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary neuromonitoring service and separate payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOmalizumab for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information received from the provider shows that the blood work result is not in the range needed for this medication to be effective.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found total IgE levels were measured at 4758 on 7/13/2020. Xolair 375 every 2 weeks was requested, but denied. The available evidence does not support prescribing Xolair for those with very high IgE levels such as in this case due to higher risk of adverse reactions and lack of effectiveness. The prescribing physician did not sufficiently justify this request and didn't show any recent updates in the literature or special circumstances in this case to support Xolair use. Therefore, the documentation does not support that omalizumab is medically necessary 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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOmalizumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care (99232) provided on September 16, 2019.You asked the Plan to pay forthe subsequent hospital care. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 99232 is not supported as being separate from CPT code 11030 which has been approved and paid.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, we have confirmed that code the subsequent hospital care has a bundled relationship with code 11030 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (99232) provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on July
22, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the
documentation does not support evidence of an established relationship between the enrollee and the ordering
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and
G0482 provided on July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services coded 29827 provided on February 18, 2020.You asked the Plan to pay for the arthroscopy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 29827 is arthroscopy, shoulder, surgical; with rotator cuff repair.We find that CPT code 29827 is not supported in the medical record. Specifically, code 29827 with modifier RT (right side) was billed. The operative report did not include documentation of a surgical shoulder arthroscopy, with rotator cuff repair. There is a more accurate code should be used as an open cuff repair was eventually performed.Based on this information, we decided that Medicare rules for coverage of the arthroscopy services have not been met.Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded 29827 provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for obstetrics/gynecology visits provided on December 6, 2019 and January 2, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you are unable to pay these copayments due to financial hardship. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $32 copayment for each specialist visit in 2019 or 2020. There were 2 visits, resulting in a total copayment obligation of $64. You have been asked to pay $32 copayment for each specialist visit. Specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 obstetrics/gynecology visits provided on December 6, 2019 and January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder orthosis (L3670) provided January 7, 2020.You asked the Plan to pay forthe shoulder orthosis. You say that the item was medically necessary.The Plan deniedyour request. The Plan says the rules for telehealth were not met and the records do not support the item billed.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. The record shows no established relationship between the enrollee and the ordering physician. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora shoulder orthosis (L3670) provided January 7, 2020.