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

We decided that the Plan does not have to pre-approvefacet joint nerve destruction treatment (radiofrequency ablation) for the enrollee.You asked the Plan to pre-approvethe treatment. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary and cannot be approved.The Plan must follow Medicare rules. Medicare rules say that items and servicesthat 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 the treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnostic medial branch blocks should be interpreted as negative, as there was only 5-10% pain relief achieved. Therefore, the request is not medically reasonable or 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 the treatment have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet joint nerve destruction treatment (radiofrequency ablation) for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment forthe emergency room visit provided on September 26, 2020.You asked the Plan to waive the copayment forthe emergency room visit. Yousay that you did not receive any services at the first emergency room you visited. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regardingtheir decision to deny your request. There were no medical records submitted from the hospital facility at issue. Therefore, we cannot determine if any services were rendered at the emergency room. Therefore, we decided that the Plan has to waive the copayment forthe emergency room visit provided on September 26, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review.The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on August 16, 2019.You asked the Plan to pay forthe physician services. You say that you did not receive proper notice of the enrollee's benefit determination.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the physician services was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe physician services provided on August 16, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveContour next test strips.You asked the Plan to pre-approvethe strips. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the requested blood glucose testing item/system is not one of the Plans preferred Part B systems. The Plan states the preferred systems are: Roche systems-Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus, and others; OR Trividia systems-TrueMetrix and TrueTrack. The Plan states they have not been given medical reasons indicating: the Plan's preferred systems have failed or are contraindicated; OR that the requested system is medically necessary. The Plan states to help with a transition, per the Medicare guidance, the Plan's physician reviewer has approved the requested item through April 1, 2021, (the first 90 days of this first year in a new plan) and per this guidance, given the Plan's current information, no subsequent refills were approved.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary arenot covered. 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 strips have not been met. The Plan is allowing coverage until April 1, 2021, because that is theenrollees first 90 days with the Plan. After that, the enrollee will have to transition to one of the preferred brands if they want these supplies covered at no charge. If they choose not to use a preferred brand, they will have to pay for it.Therefore, we decided that the Plan does not have to pre-approveContour next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged evaluation and management services excluding 
direct patient care (99358) provided on October 1, 2020, and October 2, 2020. 
 
You asked the Plan to pay for prolonged evaluation and management services excluding direct patient care. 
You say that this code is supported in the records. The Plan denied your request. The Plan says these services 
were not coded correctly. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
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 prolonged evaluation and management 
services excluding direct patient care. Our reviewer says that the use of this code is not supported. Our 
physician reviewer found although the submitted medical records include the total time spent on indirect 
patient care, the documentation is not clear on time spent off-unit to confirm this service has been provided on 
either date of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prolonged evaluation and management services excluding direct patient care 
have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and 
management services excluding direct patient care (99358) provided on October 1, 2020, and October 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for rehabilitation chiropractic services provided from July 2,
2019 to July 9, 2019.

You asked the Plan to pay for these services. You say that this treatment was medically necessary, The Plan
denied your request. The Plan says the treatment provided was not covered by Medicare. We overturned the 
Plan's denial stating there was an issue with Plan contract or Evidence of Coverage submitted for review. The 
Plan requested a reopen and clarified the information provided regarding the Plan contract.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that the only chiropractic
service Medicare covers is manual manipulation of the spine to correct a subluxation. The treatments provided
other than manual manipulation of the spine are not covered by Medicare or the health plan. The records show
that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not
have to pay for rehabilitation chiropractic services provided from July 2, 2019 to July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C 500mg infusion (J1561). 
 
You asked the Plan to pre-approve the Gamunex-C 500mg infusion. You say that the infusion 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 Intravenous Immunoglobulin is covered for 
Treatment of Myasthenia Gravis (MG) in patients who have profound, rapidly progressive, and/or potentially 
life-threatening muscular weakness. 
 
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 Gamunex-C 500mg infusion. Our 
reviewer says that the requested infusion is not medically necessary. Our physician reviewer found the provider 
noted the goal of the treatment is for treatment of decreased cognition and erectile dysfunction. The record does 
not show profound, rapidly progressive, and/or potentially life-threatening muscular weakness. 
 
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 Gamunex-C 500mg infusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Gamunex-C 500mg infusion (J1561).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc.You asked the Plan to pre-approveSynvisc. 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 suchcriteria 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 Synvisc. 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 osteoarthritis in the left knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc.  Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc is not approved as step criteria is not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forIV therapy services provided from June 18, 2020, to July 18, 2020.You asked the Plan to waive the copayment forthe IV therapy services. You say that you pay premiums so you shouldn't owe large amounts.The Plan denied your request. The Plan says you were charged the copayments correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for Outpatient Hospital services. You have been asked to pay a $350 copayment for the IV therapy services. The IV therapy services falls within the Outpatient Hospital services benefit category. The allowed amount is $184.91 which is why your copayments are less. You were charged this amount until you met your in-network out of pocket maximum. 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 forIV therapy services provided from June 18, 2020, to July 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on August 3, 2020.You asked the Plan to pay forthe chiropractic services. You say that you should only have a $15 copayment.The Plan denied your request. The Plan says they only cover manual manipulation of the spine to correct subluxation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Review of the file show that you received chiropractic services on August 3, 2020. The health plan contract says that the Plan only covers manual manipulation of the spine to correct subluxation. Therefore, the other services provided by the chiropractor are not covered.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided on August 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on June 4, 
2020. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod Dash pods.

You asked the Plan to pre-approve Omnipod Dash pods. You say that this medication is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Omnipod Dash pods. 

Benefits for Omnipod Dash pods 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 Nitroglycerin. 
 
You asked the Plan to pre-approve Nitroglycerin. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Nitroglycerin 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 Nitroglycerin.  
 
Benefits for Nitroglycerin 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel, Dexamethasone, and Diphenyydramine. 
 
You asked the Plan to pre-approve Paclitaxel, Dexamethasone, and Diphenyydramine. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Paclitaxel, Dexamethasone, and Diphenyydramine as part of a 
clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.  Therefore, we 
decided that the Plan does not have to pre-approve Paclitaxel, Dexamethasone, and Diphenyydramine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the hospital outpatient clinic visit provided 
on January 13, 2020. 
 
You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the cost for each outpatient hospital visit.  
 
You have been asked to pay 20% of the cost for the services provided. The services fall within the outpatient 
hospital services 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 cost share for the hospital outpatient 
clinic visit provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R injections. 
 
You asked the Plan to pre-approve Humulin R injections. You say that you say that the enrollee has tried and 
failed Lantus, Levemir, Apidra, Novolog, Humalog. You also say that the enrollee continues to have elevated 
blood glucose levels. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Humulin R injections.  
 
Benefits for Humulin R injections 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 95812) provided on July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 95812 is "Electroencephalogram (EEG) extended 
monitoring; 41-60 minutes". 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use 
of CPT code 95812 is not supported by the records provided. Our coding reviewer found that the procedure 
report does not document extended monitoring to confirm this service was performed. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 95812) provided on July 6, 2020.