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

We decided that the Plan does not have to pre-approve Nulojix.

You asked the Plan to pre-approve Nulojix. 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.

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 Nulojix. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found you have a past medical history of a renal transplant. Based on the medical records provided and data in the Medicare-approved drug compendia there is no documentation that the requested use of Nulojix is FDA-approved for your diagnosis with Epstein Barr virus (EBV) seronegative status or with unknown EBV serostatus. There are no drug compendia that supports the requested use. Therefore, you do not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix have not been met. Therefore, we decided that the Plan does not have to pre-approve Nulojix.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2393).

You asked the Plan to pay for the dental services. You say that the network dentist was not taking patients and the services were medically necessary. The Plan denied your request. The Plan says out-of-network dental services 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. Only dental services obtained from network providers are eligible for coverage. Therefore, we decided that the Plan does not have to pay for dental services (D2393).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 codes 28615 and 20902 are 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 28615 is open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed. The definition of code 20902 is bone graft, any donor area; major or large.

We find that CPT codes 28615 and 20902 are not supported in the medical record. Specifically, there is no documentation of open treatment of a tarsometatarsal joint dislocation, including internal fixation, for the amount of units requested to support code 28615. There is no documentation of a major or large bone graft to support code 20902. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0364, D3348).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed are not covered benefits.

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 dental services (D0364, D3348).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), or pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided by an OON provider.

You asked the Plan to pay for the bitewing x-rays, and pay more for the periodic oral evaluation and prophylaxis. You say that all of these services were for preventive care. The Plan denied your request. The Plan says bitewing x-rays are not a covered benefit. The Plan also says that the charges for the periodic oral evaluation and prophylaxis were processed correctly.

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, bitewing x-rays (D0274) are not among those covered under this benefit. The contract also clearly states that when you see an in-network provider, you may pay less for the services. The Plan also states that you were not enrolled in the comprehensive dental rider for the 2020 plan year. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274), or pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6241 and D6740) for the enrollee.

You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says this 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 pre-approve dental services (D6241 and D6740) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services.

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. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate primary diagnosis 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 emergency room (ER) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment (97810).

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under the contractual policy or by Medicare for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture treatment have not been met. Specifically, Medicare rules state that limited coverage is provided only for patients with chronic low back pain (CLBP). The documentation provided does not indicate that the enrollee has been diagnosed with chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment (97810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an eye exam (92012) and ultrasound (76514).

You asked the Plan to waive the copayments for the eye exam and ultrasound. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct amounts were 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 $20 copayment for ophthalmologist or optometrist visits and a $10 copayment for ultrasounds.

You have been asked to pay a $20 copayment for the eye exam, which falls within the Ophthalmologist visits category, and a $10 copayment for the ultrasound. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an eye exam (92012) and ultrasound (76514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (A9999, L3040, L3060).

You asked the Plan to pay for the foot orthotics. You say that these items were medically necessary. The Plan denied your request. The Plan says this provider does not participate in the Medicare program.

The Plan must follow Medicare rules. Medicare rules say that A DMEPOS supplier must submit a completed application to CMS to furnish Medicare-covered items including required enrollment forms.

We looked at the file and Medicare rules. The supplier that provided the items was not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the foot orthotics have not been met. Therefore, we decided that the Plan does not have to pay for foot orthotics (A9999, L3040, L3060).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower leg x-ray.

You asked the Plan to pay for the lower leg x-ray. You say that the enrollee was not under hospice care at the time of admission for the broken hip. The Plan denied your request. The Plan says the Medicare Hospice benefit, through fee-for-service Medicare, covers all Hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for- service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the lower leg x-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ForeseeHome Eye Monitoring Device (0379T).

You asked the Plan to pre-approve the ForeseeHome Eye Monitoring Device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that the Category III CPT Code description does not establish a service or procedure as safe, effective or applicable to the clinical practice of medicine. 

We looked at the file and Medicare rules. The item requested uses a Category III CPT code which denotes an emerging technology. This item is not listed in the relevant Local Coverage Determination as being covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the ForeseeHome Eye Monitoring Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a ForeseeHome Eye Monitoring Device (0379T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you 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 $35 copayment for outpatient rehabilitation services.

You have been asked to pay a $35 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayment for outpatient rehabilitation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0431, D9630, D4921, D4381).

You asked the Plan to pay for the dental services. You say that the dental services should be covered. The Plan denied your request. The Plan says these services are not covered benefits.

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 dental services (D0431, D9630, D4921, D4381).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001).

You asked the Plan to pre-approve a standard wheelchair (K0001). You say that the requested standard wheelchair (K0001) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested standard wheelchair (K0001).

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 standard wheelchair (K0001). Our reviewer says that the enrollee does not meet criteria for the requested standard wheelchair (K0001). Our physician reviewer found the Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) criteria for a manual wheelchair have not been met. The documentation does not indicate the enrollee has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The enrollee's mobility limitation is sufficiently resolved currently by the use of a walker in the home. Use of a manual wheelchair will not currently significantly improve the enrollee's ability to participate in MRADLs in the home.

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 standard wheelchair (K0001) have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (990832, 99213).

You asked the Plan to pay for the psychotherapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were out-of-network and were not pre-authorized. There were network providers available.

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 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 psychotherapy services (990832, 99213).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services.

You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found for the dates of service at issue the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 facility services have not been met. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (G2025).

You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The Plan denied your request. The Plan says a required modifier was not included.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G2025 is not supported in the medical record. Specifically, additional required codes were not included. The required "-95" modifier was not included. Based on this information, we decided that Medicare rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services (G2025).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bone graft (D7953).

You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says this 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 pre-approve a dental bone graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional payment for dental services (D2331, D2392, D2393).

You asked the Plan to pre-approve the services. You say that you were not aware of the benefit. The Plan denied your request. The Plan says this has been approved up to the maximum benefit allowable, and the remainder will be your responsibility.

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 $1,000 per year of dental services. 

The plan has approved $1000 worth of dental services from this appeal. If there are any remaining charges, it will be your responsibility. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional payment for dental services (D2331, D2392, D2393).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like approval for these services. The Plan denied your request. The Plan says these services can be provided in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are not able to stand. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.