Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat cervical epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation of 50% pain relief for eight weeks following a previously performed cervical epidural steroid injection.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had five cervical epidural steroid injections within a year. This request exceeds utilization criteria and therefore, it is considered 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat cervical epidural injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by the requested provider.

You asked the Plan to pre-approve the psychotherapy services to be provided by the requested provider. The Plan denied your request. The Plan says members may obtain services from an out-of-network provider only when providers of specialized services are not available in-network and the Plan does not have a contracted provider, or in urgent and/or emergent situations.

The Plan must follow Medicare rules. Medicare rules say that that a Marriage Family Therapist is not eligible to participate in the Medicare program. 

We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Except for emergency care or urgently needed services or when in-network providers are not available that you get from an out-of-network provider. Based on the available clinical information and the EOC, your request cannot be approved because the follow up office visit is not considered urgent or emergent and is available 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical trial services.

You asked the Plan to pre-approve the services. You say that this should be covered under the plan. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve the services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve clinical trial services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that a step therapy exception needs to be granted.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the required step therapy drugs. There is no documentation that the plan's required drugs would likely be less effective and/or likely have adverse effects. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit.

You asked the Plan to pay for the annual wellness visit (G0438). You say that your visit in January was not a
wellness visit. The Plan denied your request. The Plan says the claim for your visit in January was submitted as
a wellness visit and paid.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Both claims were submitted as annual wellness visits. Therefore, we decided that the Plan does not have to pay
for the annual wellness visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were discharged home but got worse and ended up back in the hospital. You say that if you were admitted until the pneumonia was cleared you wouldn't have been billed for this hospital stay. The Plan denied your request. The Plan says the copayment applied 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 a $275 copayment each day for days 1 to 5 for in-network, Medicare-covered hospital care.

You have been asked to pay an $825 copayment for the inpatient stay. ($275/day x 3 days = $875). The inpatient stay falls within the "Inpatient Hospital Care" 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 the inpatient stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee.

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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes
will be considered part of the same panel.

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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation indicates that the review of the available clinical case notes indicates that the
molecular pathology testing has been completed. The member had molecular pathology testing. 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or
more genes in a patient in parallel. Three or more genes will be considered part of the same panel. A panel
constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. The review
indicates that the services at issue in this case are 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 pay for laboratory services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid The Plan denied your request. The Plan says the rendering physician group is not in-network. The Plan says that the member's primary care physician did not refer these 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 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 items/services. Therefore, we decided that the Plan does not have to pay for physician services 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 personal medical alert system.

You asked the Plan to pre-approve a personal alert system. You say that you need a personal medical alert system. The Plan denied your request. The Plan says a personal medical alert system is not covered by Medicare or the Plan.

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. A life alert system is an emergency communications system which does not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a personal medical alert system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 and 72170.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed were already processed.

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 codes 71045 and 72170 are not supported in the medical record. Specifically, the submitted documentation supports one unit of each of these codes billed. The documentation supports that one unit was already processed and paid by the plan. There is no additional documentation supporting additional studies which were billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 and 72170.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair with accessories. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for coverage of durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that a Group 3 power wheelchair with accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and six extractions.

You asked the Plan to pay for the first intraoral periapical x-ray and extractions. You say that you do not feel
that you should be responsible for the entire bill for these services. The Plan denied your request. The Plan says
these 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. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray and six extractions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and hospital services.

You asked the Plan to pay for physician visits. You say that you were not able to return to the United States until July 2020 due to travel restrictions, so you were not able to submit these claims. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these claims were not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for physician visits was not filed until August 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit and hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).

You asked the Plan to pre-approve the partial dentures. You say that you need these dentures, and you selected this Plan solely because you were told they would be covered. The Plan denied your request. The Plan says dentures are not covered by Medicare or by the Plan's 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty advanced power wheelchair with tilt.

You asked the Plan to pre-approve a heavy-duty advanced power wheelchair with tilt. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment in a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that a heavy-duty advanced power wheelchair with tilt is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty advanced power wheelchair with tilt.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient rehab for continued close medical management. The Plan denied your request. The Plan says the enrollee can safely receive necessary services in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation, complete series of intraoral x-rays,
four resin-based composites of two surfaces, and resin-based composite of one surface. We decided that the
Plan does not have to pay for the caries risk assessment and documentation.

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, four resin-based
composites of two surfaces, and resin-based composite of one surface, and caries risk assessment and
documentation. You say that prior to this appointment you had checked to make sure this provider was in-network
with your plan. The Plan says that these services were rendered by an out-of-network provider. The
Plan also says that services provided by an out-of-network provider are not covered under the benefit program.

We decided that the Plan has to pay for the comprehensive oral evaluation, complete series of intraoral
x-rays, four resin-based composites of two surfaces, and resin-based composite of one surface.

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 record shows that you received a comprehensive oral evaluation, complete series of intraoral x-rays, and
resin-based composites. These services are listed as being covered in the Plan's 2020 EOC. The Plan also states
that it was confirmed this treating provider is in-network with your plan. You reasonably believed these
services would be covered, because they are listed as covered services, and you checked to make sure this
provider was in-network. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation,
complete series of intraoral x-rays, four resin-based composites of two surfaces, and resin-based composite of
one surface.

We also decided that the Plan does not have to pay for the caries risk assessment and documentation.

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 caries risk assessment and
documentation is not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the caries risk assessment and documentation.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic LightBox (item code E0203).

You asked the Plan to pre-approve LightBox. You say that this LightBox would help with your condition. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this item is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic LightBox is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LightBox have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic LightBox (item code E0203).