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

We decided that the Plan does not have to pre-approve three additional months of Fam-trastuxumab deruxtecan for the enrollee.
You asked the Plan to pre-approve the additional treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the diagnosis code is off-label, and has not been approved for PAP assistance by the FDA.
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 additional treatment. Our reviewer says that the requested additional months are not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Stage IV esophageal adenocarcinoma with metastatic lesions noted in the liver. The enrollee has been treated for his disease since 2017. The plan has approved a 3 month treatment of Fam-trastuxumab deruxtecan for as the enrollee has no other treatment regimen options. The provider requested 6 months. Review of the documentation does not support that a treatment duration of more than 3 months is medically reasonable and necessary at this time. 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 additional treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve three additional months of Fam-trastuxumab deruxtecan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has chosen to implement step therapy rules for Euflexxa.
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 services. Our reviewer says that the requested drug is not medically reasonable or necessary, and does not meet the step therapy coverage requirements. Our physician reviewer found the enrollee tried and failed Monovisc. Based on the medical records provided, there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Drugs
Decision: Unfavorable


We decided that the Plan does not have to pre-approve Lidocaine 5% ointment for the enrollee.
You asked the Plan to pre-approve the ointment. You say that this is medically necessary. The Plan denied your request. The Plan says this dosage form of this drug is not covered on the formulary.
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 ointment. Our reviewer says that the requested ointment is not medically reasonable or necessary, and does not meet the step therapy requirements. Our physician reviewer found Lidocaine 5% ointment is not on the plan's formulary. The plan requires a trial of their formulary options including Lidocaine 2% gel and Diclofenac 3% gel before the requested drug can be approved. Diclofenac 3% gel is not indicated for treatment of the enrollee's condition; however there has been no documentation that Lidocaine 2% gel has been failed, and/or would not be medically appropriate for this enrollee. In summary, there is insufficient documentation to support a formulary exception. 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 ointment have not been met. Therefore, we decided that the Plan does not have to pre-approve Lidocaine 5% ointment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated on teeth #8 -11 and #21-27 (D7210), surgical removal or residual tooth roots (cutting procedure) teeth #12 -14 (D2750), alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces per quadrant (D7310) and other drugs and/or medications by report (D9630).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. 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 for surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and surgical removal or residual tooth roots (cutting procedure) (D2750). The records indicate you were approved for D7210 on teeth #5 -7 on July 13, 2020 with a participating dentist. Your benefit provides coverage for up to 3 simple or surgical extractions per calendar year. Therefore, your benefit has been exhausted for the 2020 plan year. In addition, the services requested for alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces per quadrant (D7310) and other drugs and/or medications by report (D9630) are not covered benefits under your 2020 dental plan. Furthermore, you can receive 20 to 50% discount on dental services. Just see a participating network Plan dentist and discount will be taken off your bill. Therefore, we decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated on teeth #8 -11 and #21-27 (D7210), surgical removal or residual tooth roots (cutting procedure) teeth #12 -14 (D2750), alveoloplasty in conjunction with
extractions-four or more teeth or tooth spaces per quadrant (D7310) and other drugs and/or medications by report (D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from November 23, 2019 to January 10, 2020.
You asked the Plan to pay for the home health services. You say that this patient is a male and prostate diagnoses do match this. This was denied in error. The Plan denied your request. The Plan says this claim was billed with a sex of female being reported. This does not match the enrollee's sex or the enrollee's diagnoses.
The Plan must follow Medicare rules. Medicare rules say that the correct sex must be reported on claims in order to identify diagnosis inaccuracies. In this case, the claim form clearly lists female as the patient's sex which is not correct and does not match the diagnoses. This claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 23, 2019 to January 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 21, 2020 
to March 21, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 21, 2020 to March 21, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for an injection. We decided that the Plan does not have
to waive the coinsurance for an injection.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this
coinsurance. The Plan says that the correct coinsurance has been applied.
We decided that the Plan has to reduce the coinsurance for an injection.
The Plan cannot charge more than 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $8,964.44. The correct total amount you are being asked to pay is $1,792.89 ($8,964.44 x 20% =
$1,792.89).
Therefore, we decided that the Plan has to reduce the coinsurance for an injection.
We also decided that the Plan does not have to waive the coinsurance for an injection.
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 20%
coinsurance for an injection. Therefore, we decided that the Plan does not have to waive the coinsurance for an
injection.
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging (78451) 
provided April 6, 2020. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct copayment 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 $225 
copayment for advanced imaging services.  
 
You have been asked to pay a $190 copayment for the myocardial perfusion imaging. The myocardial 
perfusion imaging falls within the advanced imaging services benefit category. In this case, the allowable 
amount is less than the $225 noted in the plan contract. 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 
myocardial perfusion imaging (78451) provided April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on February 26, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 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 molecular pathology services provided on 
February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (CPT 95937) provided to the
enrollee on September 16, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 95937-26 (1 Unit) remains not supported, as the
documentation indicates that train of four testing was performed.
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 95937 is "Neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method."
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
services provided in this case were provided in the context of intraoperative monitoring. Formal testing of the
neuromuscular junction is not commonly performed during intratoperative monitoring, such as in this case.
Rather, the services performed (based on the records provided for review) reflected that train of four testing
was performed/rendered. This would not have met the definition of CPT code 95937.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for neuromuscular junction testing (CPT 95937) provided to the enrollee on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) 
provided on March 5, 2020. 
 
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate 
diagnosis code.  
 
We looked at the file and Medicare rules. The billed diagnosis code, C45.9, is not listed as an appropriate code. 
Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan 
(78815) provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-approval for periodontal scalings and root planings 
(D4341) of the upper right, lower right, upper left, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the scalings 
and planings when the services are medically necessary and reasonable.  
 
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 scalings and planings. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation submitted 
does not support the need for periodontal scaling and root planing (D4341) in all four quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pre-approval for periodontal scalings and root planings (D4341) of the upper 
right, lower right, upper left, and lower left quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis, heel stabilizer, the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on March 11, 2020.
You asked the Plan to pay for the ankle foot orthosis (L1971), heel stabilizer (L3170), the knee orthosis (L1851) and suspension sleeve (L2397) and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies.
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. The documentation submitted did not include an itemized shipping/billing invoice. 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 ankle foot orthosis, heel stabilizer, the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on March 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 1, 2018 to September 6, 2018 and from September 15, 2018 to September 30, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 1, 2018 to September 6, 2018 and from September 15, 2018 to September 30, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for vision field exam provided by a participating provider on March 4, 2020 to March 16, 2020.
You asked the Plan to waive the coinsurance for vision field exam. You say that you were told that you would not have a copayment. The Plan denied your request. The Plan says that the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for vision care. The Plan says you must pay a 20% coinsurance for vision field exam. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for vision field exam. Therefore, we decided that the Plan has to waive the coinsurance for vision field exam provided by a participating provider on March 4, 2020 to March 16, 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 for an urgent care clinic visit provided on March 10, 2020.
You asked the Plan to pay for the urgent care clinic visit. You say that you were very sick, and your son took you to the nearest urgent care clinic. You say that you were unaware that this clinic was out-of-network until you received the bill. The Plan denied your request. The Plan says you must use network (contracted) providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, and cases in which the Plan authorizes the use of out-of-network providers. You received urgent care services while there were in-network options you could have used.
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 service 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 an urgent care clinic visit provided on March 10, 2020.