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

We decided that the Plan does not have to pre-approve Synvisc Injections.
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc must be done before alternatives can be considered.
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 Synvisc. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there was no trial of the plan preferred agents. The records do not show any reason why they would be contraindicated for this 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc Injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, urinary tract infection and chronic abdominal wound after bladder tumor resection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs are clear. She was alert with confusion. Regarding rehabilitation services, the enrollee received physicaltherapy and occupational therapy in the acute hospital. The enrollee was at a modified independent level with functional mobility including gait to 320 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs.  The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity ofservice 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 2, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the provider is not in-network and there is no authorization on file.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 nota network provider with the Plan. The Plan did not pre-approve the servicesat 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 forsubsequent nursing facility care provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 28, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that you wanted to appeal the Plan's denial of payment for the ambulance services. You say that you were told the claim was denied because authorization was required but not received.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tertiary care visit with an orthopedic surgeon.You asked the Plan to pre-approvea tertiary care visit with an orthopedic surgeon. You say that it is medically necessary to see the requested specialist.The Plan denied your request. The Plan says the requested specialist is not appropriate for the services required. The Plan states that you are approved to consult with a community specialist in orthopedics. The Plan instructs you contact your primary care physician for further questions or options.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that specialists require prior authorization. The requested provider is not appropriate in this case. The Plan has approved a more appropriate provider for the services required. Therefore, we decided that the Plan does not have to pre-approvea tertiary care visit with an orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on May 1, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no 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 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 an office visit provided to the enrollee on May 1, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. He has not triedand failed the plan's required drugs of Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee; therefore, Synvisc One is not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc One
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuity of care with the out-of-network neurosurgeon. You asked the Plan to pre-approvecare with an out-of-network neurosurgeon. You say that the enrollee has been seeing this out-of-network provider in 2018 and 2019. You say that an appeal was filed last year as well and it was approved.The Plan denied your request. The Plan says the doctor is not part of the enrollee's health plan. The Plan says that the enrollee is able to get care in-plan.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contractproviders for care. 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 care with an out-of-network neurosurgeon. Our reviewersays that the criteria for out-of-network care have not been met. Our physician reviewer found the enrollee is not current receiving any active treatment or medical management that makes it medically necessary to continue care with the out-of-network provider as requested. There is nothing unique about the enrollee's condition that would make it medically necessary for her to continue care with the out of network doctor. The enrollee had previously undergone coiling of ta cerebral aneurysm. The notes provided for review,from 2019, indicate that her cerebral angiogram in late 2018 was stable. The enrollee only requires periodic monitoring, to look for interval changes should they arrive. These can be easily managed by another provider. The enrollee's medical management and follow-up care can be safely transitioned to an in-network specialist.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of care with an out-of-network neurosurgeonhave not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuity of care with the out-of-network neurosurgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833-RT) provided on April 16, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not contain a valid physician order for the orthosis at issue.
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 shows that the Plan made several attempts to obtain the physician order documentation for the item at issue in this appeal. The record does not contain a valid physician order for the orthosis provided in this case. The order in the documentation is for a different orthosis. Therefore, we decided that the Plan does not have to pay for the right knee orthosis coded as (L1833-RT) provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99291 provided on July 27, 2019.
You asked the Plan to pay for CPT code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, CPT code 99291 is a time based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for July 27, 2019 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of CPT code 99291. Based on this information, we decided that Medicare rules for coverage of CPT code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99291 provided on July 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on August 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for drug testing. You say that you are an independent laboratory who relies on the referring physician to obtain prior authorization. If authorization is not obtained you should not be penalized for the error. The Plan denied your request. The Plan says the Provider is a non-participating provider. They did not authorize any services for the Facility or the Provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent or emergent in nature.
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 drug testing (G0483, 80307) provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 5, 2019.
You asked the Plan to pay for the dental service. You say that you went to this provider for a second opinion. You say that your previous dentist was charging more for additional dental services that you needed. The Plan denied your request. The Plan says bitewing x-rays are covered once per plan year. The Plan also says that the frequency limit has been exceeded.
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 and bitewing x-rays are a covered service, the frequency limit of once per plan year has been exceeded. The record shows that the Plan paid for the bitewing x-rays that you received on March 7, 2019. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 10, 2019 through January 11, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plandenied your request. The Plan says that the stay is 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 record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. Inpatient admission was medically 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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from January 10, 2019 through January 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the PT services provided on July 11, 2019 to July 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services.
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 PT services provided on July 11, 2019 to July 17, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had extremely low blood sugar and your spouse could not correct it. Your spouse called 911 and the responders administered an IV to get your blood sugar to a normal level. You say that after the initial treatment, there were no further services required including a hospital visit, transportation or a doctor visit. You say that after the responders' treatment you were functioning normally. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 16, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says with the information provided, it cannot be determined whether the services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records for the date of service in question. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on August 16, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left shoulder rotator cuff repair (23412, 29822).
You asked the Plan to pre-approve left shoulder rotator cuff repair. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 left shoulder rotator cuff repair. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would support surgical intervention in this enrollee's medical condition based on their persistent pain and functional limitations, clinical and imaging findings of rotator cuff tear and impingement, and failure of 4 years of reasonable conservative management. Therefore, this request for left shoulder rotator cuff repair is medically reasonable and 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 left shoulder rotator cuff repair have been met. Therefore, we decided that the Plan has to pre-approve left shoulder rotator cuff repair (23412, 29822).
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.