Persius/hicric huggingface dataset:
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 you have high arches and need the inserts for support. The Plan denied your request. The Plan says the services are not covered.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ILUMYA (J3245).
You asked the Plan to pre-approve ILUMYA (J3245). You say that you want the enrollee treated with this
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to Remicade, Inflectra and STELARA.
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 ILUMYA (J3245). Our reviewer says
that the drug is not medically necessary. Our physician reviewer found there is no evidence that the enrollee is
allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and
not responded to these other forms of medication. There is no documentation as to why these other forms of
medication would not be expected to be safe and effective for the enrollee. Therefore, the requested ILUMYA
is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ILUMYA (J3245) have not been met. Therefore, we decided that the Plan does
not have to pre-approve ILUMYA (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided on July 22, 2020.
You asked the Plan to pay for the GeneSight Psychotropic test. You say that you would like reconsideration because this should be a covered service. The Plan denied your request. The Plan says the ordering physician does not satisfy Medicare's qualification criteria.
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic test have not been met. Specifically, the record indicates that the ordering physician is an internal medicine doctor. This does not meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea special genetic test for the enrollee.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information sent in does not show how this test will help medical management.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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with non-Hodgkin, follicular lymphoma.  Testing specifically related to the lymphoma, for which associated therapies are known, is medically necessary and reasonable. Testing unrelated to the lymphoma or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the testing is medically necessary or reasonable.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 test have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea special genetic test for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 29, 2020, to August
3, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that the services provided were not medically
necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the patient had already failed outpatient therapy with appropriate oral antibiotics. Therefore, the
admission was justified based on the enrollee's medical condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from July 29, 2020, to August 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta (J3304).
You asked the Plan to pre-approve Zilretta. You say that the service was medically necessary. The Plan denied your request. The Plan says that you already had an injection of this medication and according to Covereage Review Guidelines, Zilretta is not intended for repeat administration. The FDA noted as a limitation of approval, that the safety and efficacy of Zilretta in repeat administration was not known.
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 Zilretta. Our reviewer says that the service is medically necessary. Our physician reviewer found Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. The product label does not preclude use of the drug more than one time. The documentation supports that Zilretta is medically reasonable and necessary and is safe and effective for your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have been met. Specifically, the service is safe and effective for your intended use. Therefore, we decided that the Plan has to pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and x-rays provided by a participating provider on July 24, 2020.You asked the Plan to waive the copayment for a specialist office visit and x-rays. You say that you paid the $35 copayment. You say that you were never notified that you would have a $20 copayment for each x-ray. The Plandenied your request. The Plan says the correct copayments have been 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 $35 copayment for podiatry services and a $20 copayment for outpatient diagnostic tests/x-rays. You have been asked to pay a $35 copayment for a specialist office visit and a $20 copayment for each x-ray. The total amount you are being asked to pay is $75 ($35 + $20 + $20 = $75). A specialist office visit falls within the podiatry services benefit category and x-rays fall within the outpatient diagnostic tests/x-rays 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 a specialist office visit and x-rays provided by a participating provider on July 24, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the thorax (71250).You asked the Plan to pre-approvea CT scan. You say that this is medically necessary.The Plan denied your request. The Plan says this is not indicated at this time.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the medical records show that you had a 9 mm pulmonary nodule in the left lower lobe seen on a CT scan on August 20, 2019. A followup CT on November 15, 2019 showed resolution of this nodule. Further imaging followup of this nodule is not medically necessary since this nodule has resolved.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the thorax (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the enrollee's healthcare provider sent this
specimen to your laboratory for analysis. The Plan denied your request. The Plan says the denial of payment
for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is
also out-of-network with the Plan.
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 medical services provided on September 4,
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels (E0637).
You asked the Plan to pre-approve combination sit to stand frame/table system. You say that you need the equipment because you cannot move or sit down. You cannot lift your leg and cannot put any weight at this time. The Plan denied your request. The Plan says this item is not covered benefit because Medicare does not consider standing tables to be primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels (E0637).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medial Branch Block injections.
You asked the Plan to pre-approve steroid injections. You say that you need the injections for pain relief. The Plan denied your request. The Plan says the physician notes do not show you have tried other forms of conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no record of conservative care such as NSAIDS, acetaminophen or physical therapy. Based on this information, we decided that Medicare rules for coverage of steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Medial Branch Block injections.
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 you hope to avoid surgery. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you provided lab services that were referred. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210).
You asked the Plan to pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of
tooth, and including elevation of mucoperiosteal flap if indicated. You say that the services are medically
necessary. 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 pre-approve
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you
have not had two diagnostic blocks, or prior conservative treatments.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain
medical indications.
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 requested services. Our physician
reviewer found that you have chronic pain syndrome, thoracic spine pain and spondylosis of the thoracic region
without myelopathy or radiculopathy. The request is for facet joint radiofrequency ablation. The provided
documents show that you previously had a diagnostic block with 80-90% percent pain relief on December 3,
2020, as well as another diagnostic block on August 12, 2020, with 60% relief. A detailed description of prior
conservative treatments is not included with the provided documentation. The provided medical records do not
document that you have satisfied the above stated requirements. Therefore, this procedure is not medically
necessary and reasonable.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95813) provided on December 4, 2019.
You asked the Plan to pay for an electroencephalogram. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. When a service is rendered to a patient who is a registered inpatient or an outpatient of a hospital the correct POS code is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus). We looked at the file and Medicare rules. The record shows that the services at issue were billed with POS 15 for a mobile unit, but the enrollee was a registered inpatient or an outpatient of a hospital. Based on this information, we decided that Medicare rules for coverage of an electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95813) provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining chiropractic services provided from July 22, 2020, to August 7, 2020.
You asked the Plan to pay for the remaining chiropractic services. You say that the doctor is in network so the Plan should pay this claim. The Plan denied your request. The Plan says they will cover chiropractic manipulative treatment but the other treatments are non-covered.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the remaining chiropractic services provided from July 22, 2020, to August 7, 2020.
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 you have foot pain. 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.