Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been
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 Evenity. Our reviewer says that the
requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a
trial of Zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed the
preferred drug. There is no documentation that the Plan's preferred drug would likely be less effective and/or
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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve treatment with Evenity (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cryoneurolysis of the genicular nerves 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 enrollee should undergo surgical evaluation for total knee arthroplasty.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found cryolosis of a nerve is not considered radiofrequency ablation and should not be coded in this fashion. The use of cryolosis here is considered experimental and investigational. The request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve cryoneurolysis of the genicular nerves for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior vesicourethropexy, or urethropexy (51840) provided on February 4, 2021.

You asked the Plan to pay for the anterior vesicourethropexy, or urethropexy. 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 support the service billed.

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 51840 is anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple. 

We asked our coder 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 anterior vesicourethropexy, or urethropexy. Our reviewer says that CPT code 51840 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical and billing documentation submitted does not include a diagnosis code of N39.3, stress incontinence (female) (male) and/or N39.46, Mixed incontinence, urge and stress incontinence, which is required and was not included in the claim when it was submitted to the health plan, therefore 51840 is not eligible for reimbursement consideration. 

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 anterior vesicourethropexy, or urethropexy have not been met. Therefore, we decided that the Plan does not have to pay for the anterior vesicourethropexy, or urethropexy (51840) provided on February 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you need
assistance getting to your therapy appointments. The Plan denied your request. The Plan says you have
exhausted your transportation benefit for the 2021 plan year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of up to eighteen (18) one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has severe pain in both feet and not able to sleep or walk. 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-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the out-of-network (OON) provider on February 11, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the out-of-network (OON) provider on February 11, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7999).
You asked the Plan to pre-approve the dental service. You say that you have been to urgent care. You say that you have taken ketorolac shots for the pain from your wisdom teeth. The Plan denied your request. The Plan says the surgical extractions are not to prepare the jaw for radiation. The Plan says that the requested surgical extractions are not covered by Medicare or the enhanced supplemental dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical extraction is not among those covered under this benefit. The services you are asking the Plan to pay for involve the care,
treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the record shows that the extractions are related to wisdom tooth pain and not preparing the jaw for radiation treatment. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, thorax (71260) provided October 23, 2020.

You asked the Plan to pay for the radiology services. You say that please review and reprocess claim for reimbursement according to contract. The Plan denied your request. The Plan says the Plan is not the primary insurance. You must bill the primary insurance first and the Plan can reconsider payment.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is the secondary payer and you must bill the primary insurance. As the secondary insurer, the Plan cannot be held responsible for the radiology services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the computed tomography, thorax (71260) provided October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Abatacept infusions you received from
January 18, 2021 to March 30, 2021.

You asked the Plan to waive the coinsurance for the Abatacept infusions. You say that you were originally only
charged a copayment for these services. You feel that if the claims were to be reprocessed to charge
coinsurance, it should only be going forward, not for past services. The Plan denied your request. The Plan says
you were charged this coinsurance 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%
coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Abatacept infusions. The Abatacept infusions fall within
the Medicare Part B drugs benefit category. This coinsurance applies regardless of when and why the plan
reprocesses your claims. 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 the Abatacept infusions
you received from January 18, 2021, to March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140), intraoral periapical, first radiographic image x 2 (D0220), and resin-based composite, two surfaces, anterior (D2331) provided by an out-of-network (OON) provider on April 20, 2021, through May 11, 2021.
You asked the Plan to pay for the tooth extraction, intraoral x-rays and filling. You say that you verified with the dentist prior to signing up with the Plan that they were part of the Plan's network. You were unaware that the Plan uses a third-party dental vendor. The Plan denied your request. The Plan says the is provider is not a part of the supplemental dental network and therefore the services rendered are not covered.
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 tooth extraction, intraoral x-rays and filling when the services are provided by a dentist in the Plan's dental network.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan's supplmental dental provider. 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 services. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction, intraoral x-rays and filling have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140), intraoral periapical, first radiographic image x 2 (D0220), and resin-based composite, two surfaces, anterior (D2331) provided by an out-of-network (OON) provider on April 20, 2021, through May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of an intra-socket biological dressing (D7922), bone replacement graft (D7953), and inhalation of nitrous oxide (D9230).
You asked the Plan to pre-approve the placement of an intra-socket biological dressing), bone replacement graft, and inhalation of nitrous oxide. You say that the services are medically necessary. The Plan denied your request. The Plan says the services requested are not listed in the Plan's dental handbook, and therefore, are not covered.
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 the placement of an intra-socket biological dressing (D7922), bone replacement graft (D7953), and inhalation of nitrous oxide (D9230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 15, 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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair (D2980) provided on April 26, 2021.
You asked the Plan to pay for the crown repair (D2980). You say that the abscessed tooth with swelling was as much a medical issue as it was a dental issue. You say that you expect the Plan benefits to cover everything associated with getting back to good health. The Plan denied your request. The Plan says the service is not a covered 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.
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 crown repair (D2980) provided on April 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from February 8, 2021, through March 3, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services beginning February 8, 2021 are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term care). 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from February 8, 2021, through March 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is not sufficient documentation to support medical necessity to move to the 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you have stabilized medically, and you are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on daily basis. Further services can be received at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on October 7, 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 procedure code 77003 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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a primary procedure code. 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 fluoroscopic guidance rendered on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee would be equally well-served at an alternative 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can continue to receive further rehab services at a lower level of care. There are no acute exacerbations of chronic medical problems. Physical function is at or near the baseline, and needs can be met at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).