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

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The
Plan denied your request. The Plan says the requested Hyalgan is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
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 Hyalgan. Our reviewer says that the
requested Hyalgan is not medically necessary. Our physician reviewer found the use of Hyalgan is FDA
approved for knee osteoarthritis and more recently shoulder osteoarthritis. There is no FDA approval at this
time for hip osteoarthritis. The use is not supported by one of the major drug compendia or by clinical research
that appears in a CMS-approved medical journal. There is a lack of published, large scale, long-term
references, recent peer-reviewed literature that shows the request to be an effective and/or safe treatment for the
noted pathology.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan Supartz injections.

You asked the Plan to pre-approve Hyalgan Supartz injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this medication will be supplied by the enrollee's pharmacy and is therefore not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Hyalgan Supartz injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and each
additional intraoral periapical x-ray (D0230) provided on January 11, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that you do not understand why these
services were not covered. The Plan denied your request. The Plan says these services are not covered benefits
under your 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 first
intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) provided on January 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on September 29, 2020.
You asked the Plan to waive the copayment for an EGD. You say that you had the same procedure in the past and were not charged and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay $225, which is less than the $275 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care you received on September 29, 2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the 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 $250 copayment for each inpatient admission. 

Review of the file shows that you received inpatient care on September 29, 2020. You have been asked to pay a $250 copayment for the services. The services fall within the inpatient care 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 inpatient care you received on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the requested wireless capsule endoscopy is medically necessary. The Plan denied your request. The Plan says the requested wireless capsule endoscopy 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 wireless capsule endoscopy. Our reviewer says that the requested wireless capsule endoscopy is not medically necessary. Our physician reviewer found the enrollee is with Gastroesophageal reflux disease (GERD), prostate cancer and persistently elevated prostate-specific antigen (PSA), anxiety/depression, sleep apnea, BMI 42.4, status post orthopedic surgery, and appendectomy.
Pertinent to this review, the enrollee has a recent history of iron-responsive anemia (ferritin low at 15 on 2/4/2021; hemoglobin low at 10.4 g/dl 7/1/2020, 11.8 g/dl with MCV 82.2 on 2/4/2021, last 13.6 g/dl after ongoing iron supplementation). Stool has not been tested for occult blood. An upper gastrointestinal (GI) endoscopy and colonoscopy were performed 9/3/2020, followed by CT colonography on 9/17/2020. Respective results included: enlarged prostate, hepatic flexure lipoma, 5mm sigmoid polyp, mild sigmoid diverticulosis, non-obstructing right renal stone, bilateral fat-containing inguinal hernias, hemorrhoids, Barrett's esophagus, and gastric erythema. In addition, upper GI and small bowel follow-through 3/29/2021 proved unrevealing. Of note, despite normalization of hemoglobin to 13.6/hematocrit 42.9 with MCV 81.7, iron studies remain low as of 4/15/2021: serum iron 41 ug/dL (range 50-180), ferritin 8 ng/mL (range 24-380). The enrollee has iron deficiency, but not anemia nor demonstration of occult GI bleeding. 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 wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dupixent injection.
You asked the Plan to pre-approve a Dupixent injection. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the Dupixent injection is not covered under the
enrollee's Medicare Part B 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 a Dupixent injection.
Benefits for a Dupixent injection 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 6, 2020 by an out of network (OON) provider.

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 services were rendered by an out-of-network provider without prior authorization.

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 medical services provided on October 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on February 4, 2021.
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you did not have to pay for the supplies with a previous Plan. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for diabetic supplies and therapeutic shoes. You received diabetic supplies on February 4, 2021. The total allowed amount is $44.46 and 20% of that is $8.89. You have been asked to pay the total coinsurance amount of $8.89 for diabetic supplies. Diabetic supplies fall within the diabetes self-management training, diabetic services and supplies 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 diabetic supplies provided on February 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on February 17, 2021.
You asked the Plan to pay for the office visit. You say that the patient has a mental health diagnosis that causes them to need medical coverage and ongoing treatment. You say that the claims need to be covered because the patient does not have the resources to pay. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 office visit provided by an out-of-network provider on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic
procedure (95999) provided on May 19, 2020, by an OON provider.

You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that
this service was medically necessary. The Plan denied your request. The Plan says there was no prior
authorization obtained for these non-emergent 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 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 unlisted neurological or neuromuscular
diagnostic procedure (95999) provided on May 19, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on June 24, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that there are no in-network dentists within a closer location to you. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there are in-network providers that could have rendered the appropriate care to you.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on June 24, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided October 2, 2020.

You asked the Plan to pay for the neuromuscular stimulator. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation submitted is missing required information.

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 proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. 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 the neuromuscular stimulator (E0745) provided October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The enrollee was admitted from an outside facility due to a near fall after hip arthroplasty and was found to have a wound infection requiring extended intravenous antibiotics. The record indicates that he has not been accepted at multiple skilled nursing facilities. He continues to receive acute care services and those have not been denied. The record does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility.

Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 services provided by an out-of-network provider on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 31, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 services provided by an out-of-network provider on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 14, 2020 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that no benefits are available for procedures performed by OON providers.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 14, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the end stage renal care provided on September 24, 2020 to September 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the end stage renal care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 end stage renal care provided on September 24, 2020 to September 29, 2020 by an out of network (OON) provider.