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

We decided that the Plan does not have to pre-approve Qsymia capsules (J8499).You asked the Plan to pre-approve Qsymia capsules. You say that you recommend that Qsymia be covered as a medically necessary medication for the enrollee.The Plan denied your request. The Plan says this medication does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Qsymia capsules (J8499).
Benefits for Qsymia capsules may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on July 28, 2020.
You asked the Plan to pay for the office visit. You say that you were encouraged to go to this provider for a second opinion and treatment plan. The Plan denied your request. The Plan says the requested services were 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 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 the office visit provided by an out-of-network provider on July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided
on October 16, 2020.
You asked the Plan to pay for the CGP testing. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have
to pay for the Comprehensive Genomic Profile (CGP) testing provided on October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Renflexis.
You asked the Plan to pre-approve Renflexis. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for Renflexis have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Renflexis. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the Plan requires a trial of drugs Remicade, Inflectra, and Simponi Aria before they will approve the requested drug, Renflexis. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Renflexis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient surgery excision of excessive skin of thigh (15839).
You asked the Plan to pre-approve the outpatient surgery excision of excessive skin of thigh. You say that this request is medically necessary. The Plan denied your request. The Plan says this is considered a cosmetic surgery and not covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.
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 outpatient surgery excision of excessive skin of thigh. Our reviewer says that the requested surgery is not medically necessary and reasonable. Our reviewer found in this case the enrollee has a body mass index (BMI) of 38. The provided medical record states that this would be a cosmetic procedure. The record indicates the skin is dry. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The requested service cannot be recommended. 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 outpatient surgery excision of excessive skin of thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient surgery excision of excessive skin of thigh (15839).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared light therapy (97026-GPx3) provided November 22, 2019 to November 27, 2019.
You asked the Plan to pay for the infrared light therapy. You say that after multiple calls you were directed to the Plan and was told your original document is not detail enough. It is why you are submitting more detailed documents after the timeframe. The Plan denied your request. The Plan says infrared therapy is not medically necessary and excluded from coverage.
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. Based on this information, we decided that Medicare rules for coverage of the infrared light therapy have not been met. Therefore, we decided that the Plan does not have to pay for the infrared light therapy (97026-GPx3) provided November 22, 2019 to November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthesis with microprocessor knee.
You asked the Plan to pre-approve a prosthesis with microprocessor knee. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that microprocessor knees are only covered for certain 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 a prosthesis with microprocessor knee. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee is a K3 ambulator and gardens daily. The requested prosthetic leg with microprocessor knee exceeds the enrollee's medical needs. The documentation does not clearly reveal why the enrollee requires a microprocessor knee over a standard K3 prosthesis without a computerized knee. Therefore, the enrollee does not meet criteria for the requested microprocessor knee. 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 prosthesis with microprocessor knee have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthesis with microprocessor knee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the infusion services provided from June 24, 2019, to June 25, 2019.
You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan says the cost shares 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).
The file shows that the enrollee received infusion services at an outpatient hospital facility. She was charged a $36.57 copay, and a $57.68 copay. Because the amounts were less than the $395 copay, she was charged the lesser amounts. The services fall within the benefit category for outpatient surgery and other medical services provided at hospital outpatient facilities.
The enrollee received lab services. A $2 copay was applied. The services fall within the outpatient diagnostic test benefit category.
The enrollee received chemotherapy injections. A 20% coinsurance was applied for each injection/infusion. The services fall within the Medicare Part B prescription drug benefit category. At the time the claim for services was processed, the enrollee had not met the maximum out-of-pocket amount for the year. This means that the enrollee has been asked to pay the correct amounts based on her contract with the Plan. This cost sharing is a contractual obligation she agreed to pay when she enrolled in the Plan.
The file shows that the enrollee received Ondansetron and Loarzepam during her outpatient care. The Plan must follow Medicare rules. Drugs that are received during outpatient care, that the enrollee would normally take on her own are considered self-administered drugs. The rules say that Medicare Part B generally does not pay for self-administered drugs. These drugs at issue are not among the types which are covered by Medicare Part B. Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights. Therefore, we decided that the Plan does not have to waive the cost shares for the infusion services provided from June 24, 2019, to June 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, to January 10, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require daily skilled services on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, to January 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for each hyperbaric oxygen therapy visit (G0277) provided on October 1, 2020, to October 30, 2020.You asked the Plan to waive the coinsurance for each hyperbaric oxygen therapy visit. You say that you were told you would only have to pay a $196 copayment per week for the antibiotics and the Plan would pay for the rest.The Plan denied your request. The Plan says the coinsurance you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for each outpatient diagnostic test and therapeutic services and supplies including outpatient therapeutic services. 
The enrollee has been asked to pay a 20% coinsurance for each hyperbaric oxygen therapy visit. The allowed amount of each visit is $446, resulting in a coinsurance obligation of $89.20 per visit. The enrollee had twenty(20) visits ($89.20 x 20 visits = $1,784). The records show the enrollee also had a hyperbaric oxygen therapy visit where the allowed amount of the visit was $446, resulting in a coinsurance of $4.20, which is less than the Plan's contracted amount. The total cost share for the enrollee is $1,788.20 ($1,784 + $4.20 = $1,788.20). The EOC confirms that 20%is the required coinsurance for this service.Hyperbaric oxygen therapy falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for each hyperbaric oxygen therapy visit (G0277) provided on October 1, 2020, to October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for femoral artery exposure (34812-50-59), thromboendarterectomy (35355-50), and the access and closure of femoral arteries (34713-RT-59, 34713-LT-59) provided on May 8, 2020.You asked the Plan to pay for femoral artery exposure, thromboendarterectomy, and the access and closure of femoral arteries. You say that these services were billed correctly.The Plan denied your request. The Plan says these 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.
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 femoral artery exposure, thromboendarterectomy, and the access and closure of femoral arteries. Our reviewer says that these codes are not supported. Our physician reviewer found the operative report documents that an incision was made in each groin and each common femoral artery was dissected out using sharp dissection and electrocautery as well rather than femoral artery exposure, opened longitudinally.  Therefore, CPT 34812 cannot be confirmed as performed. The operative report also documents plaque removal rather than a thromboendarterectomy, meaning CPT 35355 cannot be confirmed as performed. Finally, CPT 34713 should not be reported twice with LT and RT, but instead reported with bilateral modifier.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of femoral artery exposure, thromboendarterectomy, and the access and closure of femoral arteries have not been met.Therefore, we decided that the Plan does not have to pay for femoral artery exposure (34812-50-59), thromboendarterectomy (35355-50), and the access and closure of femoral arteries (34713-RT-59, 34713-LT-59) provided on May 8, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the enrollee has failed greater than 24 months of conservative approaches to treatment. You say that the Medicare guidelines for coverage have been met. You say that the requested treatment is considered safe and effective and is supported by its clinical benefits to patients. The Plan denied your request. The Plan says the requested device is not reasonable and necessary.
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 Vertiflex Superion device. Our reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex Superion device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network psychologist.You asked the Plan to pre-approve the out-of-network office visit. You say that you have been under her care for two years and made strides toward your recovery from anxiety. You say that she should continue to help you through the end of this treatment.The Plan denied your request. The Plan says in-network providers are 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 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 an office visit with an out-of-network psychologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, diagnostic casts, 2D oral/facial photographic image, occlusal orthotic device, prophylaxis, and periodic oral evaluation provided from February 19, 2020, to July 29, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, diagnostic casts, 2D oral/facial photographic image, occlusal orthotic device, prophylaxis, and periodic oral evaluation. You say that these services and orthotic device were needed as a result of an accident you were in. The Plan denied your request. The Plan says the treating provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, diagnostic casts, 2D oral/facial photographic image, occlusal orthotic device, prophylaxis, and periodic oral evaluation provided from February 19, 2020, to July 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your
benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 50 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223) and therapeutic drugs (D9612).

You asked the Plan to pre-approve anesthesia and therapeutic drugs. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your 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 deep sedation/general anesthesia (D9222, D9223) and therapeutic drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 6 and 11.

You asked the Plan to pre-approve the dental services. You say that there are no dentist that accept your insurance for implant surgery. You also say that it is medically necessary for you to have this surgery. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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 and implants are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth # 6 and 11.