Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services.You asked the Plan to pre-approve the services. You say that you are requesting Home Health Aide services because you are unable to walk or write The Plan denied your request. The Plan says no clinical information was submitted to determine medical necessity.The Plan must follow Medicare rules. The rules say that services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services. Our reviewer says that home health aide services are not medically necessary. Our physician reviewer found the documentation does not support that you are homebound. The documentation indicates that you have had outpatient physical therapy services.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 pre-approve services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior 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 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 physician's services provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two extractions provided on August 12, 2019.You asked the Plan to pay forthe extractions. You say that you had a terrible abscess and your dentist referred you to this provider for it to be taken care of. You also say that you did not know, nor were you informed, that this provider was not in-network with your plan.The Plan denied your request. The Plan says no benefits are available for procedures performed by out-of-network providers or outside of the providers contracted period.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 covered when they are received out-of-network.Therefore, wedecided that the Plan does not have to pay forthe two extractions provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an enteral feeding supply kit (B4034) and formula (B4152) provided from May 16, 2019 to June 10, 2019.
You asked the Plan to pay for an enteral feeding supply kit and formula. You say that these items should be covered The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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 and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. There is neither an itemized shipping invoice that corroborates the items billed nor a proof of delivery. Therefore, we decided that the Plan does not have to pay for an enteral feeding supply kit (B4034) and formula (B4152) provided from May 16, 2019 to June 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (71045) provided July 18, 2019.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate of a previous claim.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 71045 is not supported in the medical record. Specifically, claim 820192060968330 was already paid and was for the same service on the same date. It was billed with the same code and modifiers. Based on this information, we decided that Medicare rules for coverage of the radiology serviceshave not been met.Therefore, we decided that the Plan does not have to pay forRadiology services (71045) provided July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the electronic analysis services provided to the enrollee on April 24, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
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 95972 is Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional. We asked our coding 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 provided. Our reviewer found that the medical records provided do not include documentation of an electronic analysis of implanted neurostimulator pulse generator/transmitter being performed on April 24, 2019. Procedures should be reported with the most comprehensive CPT code that describes the services performed. 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the electronic analysis services provided to the enrollee on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dialysis for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has been under your care for many months while in the hospital and you do not attend skilled nursing facilities. The Plan denied your request. The Plan says the services are available from network providers.
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 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 confirmed that the enrollee will receive dialysis services in the skilled nursing facility (SNF) where he was previously receiving care. 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 a referral for dialysis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo for the enrollee. You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan saysthe services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic adenocarcinoma of the lung. There is no prior chemotherapy noted in the submitted records. Her tumor is PDL1 positive. She had progressive cancer on treatment with Keytruda which is also a PD-1/PD-L1 inhibitor. The use of Opdivo is indicated for patients who have previously had progressive lung cancer after treatment with a Platinum based chemotherapy regimen. Further, the NCCN compendium specifies that it may be used as subsequent therapy if there is no prior progression on a PD-1/PD-L1 inhibitor. The enrollee has not had prior chemotherapy and she has had progression on such an inhibitor; therefore, Opdivo is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully reimburse you for the crown, core buildupand tissue modification provided on May 10, 2019.You asked the Plan to fully reimburse you forthe crown, core buildup and tissue modification. You say that the work was not done correctly. You say that you should be reimbursed.The Plan denied your request. The Plan says that you were reimbursed $200 for the overcharge ofthe crown. The Plan also says that these are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to fully reimburse you forthe crown, core buildup and tissue modification provided on May 10, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a behavioral health inpatient stay.
You asked the Plan to pre-approve a behavioral health inpatient stay. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 behavioral health inpatient stay. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for acute inpatient mental health treatment as you were not shown to be a danger to yourself or others, were without agitation or aggression, and were without perceptual disturbance including auditory or visual hallucinations. 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 behavioral health inpatient stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a behavioral health inpatient stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foroxygen concentrator and an accessory battery pack purchased by the enrollee from an out-of-network providerfrom January 7, 2019 through January 21, 2019.You asked the Plan to pay forthe DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Per Medicare guidelines; for oxygen andoxygen equipment, payment is not made for purchases of this type of equipment. Only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Additionally, the sales tax is not medical in nature and thereforeno payment can be made.Oxygen reimbursement is a bundled payment. All options, supplies and accessories are considered included in the monthly rental payment for oxygen equipment. Oxygen rental is billed using the appropriate code for the provided oxygen equipment. Separately billed options, accessories or supply items will be denied as unbundling. Only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.Therefore, the claims denied correctly and the member is responsible for the entire cost of the Oxygen concentrator in the amount of $3592.95.Therefore, we decided that the Plan does not have to pay foroxygen concentrator and an accessory battery pack purchased by the enrollee from an out-of-network provider from January 7, 2019 through January 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on February 22, 2019.You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on February 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D6750), and the pontic (D6210) provided on July 11, 2019.
You asked the Plan to pay for the dental services. You say that when you signed up for your plan, you were advised that crowns were covered. The Plan denied your request. The Plan says the dental services you received are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D6750), and the pontic (D6210) provided on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea third opinion to be provided by an out of network provider.You asked the Plan to pre-approvea third opinion. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services requested are neither emergent nor urgentto seek out-of-network care. The Plan states there are equally qualified in-network orthopedic surgeons the enrollee has not seen that can provide the care and treatment being requested.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 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. We found no exception that would require the Planto pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea third opinion to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex foot system (L5980)You asked the Plan to pre-approvethe flex foot system. You say that you deem this prosthesis with advanced foot feature appropriate and medically necessary.The Plan denied your request. The Plan says the enrollee does not meet the criteriaThe 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 flexfoot system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for flex foot system prosthesis not met. There is no documentation that an advanced prosthesis is needed. More documentation is needed.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 flex foot system have not been met.Therefore, we decided that the Plan does not have to pre-approveall lower extremity prostheses, flex foot system (L5980)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have ahistory of osteoporotic fracture, or contraindication to Zoledronic Acid.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 Prolia. Our physician reviewer found that the enrollee has a diagnosis of Age-related osteoporosis without current pathological fracture. It is noted that the enrollee is unable to take Bisphosphonates as she has GERD. The Plan requires a trial of Zoledronic Acid, or have ahistory of Osteoporotic fracture before they will approve the requested drug. The documentation does not show the enrollee has tried and failed the required drug. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite (D2392), and the amalgam (D2160) provided on July 31, 2019.You asked the Plan to pay forthe dental services. You say that you had 2 teeth repaired. You say that they were repaired to avoid them from getting decayed, pulled, or needing a root canal. You say your Plan covers $500 for preventive care. You also say that the services you received were preventive.The Plan denied your request. The Plan says the repairing, filling, or replacement of teeth are not covered under your 2019 benefit plan. The Plan also says you are responsible for the full amount.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin based composite (D2392), and the amalgam (D2160) provided on July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 13, 2019 to March 15, 2019 by out of network provider.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were non-emergent and notpre-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 items/services at issue in this appeal. The Plan did not pre-approve the item/serviceat 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 forthe medical services provided on March 13, 2019 to March 15, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by the out of network provider.
You asked the Plan to pre-approve an office visit. You say that the physician has been your gynecologist for over twenty years. You understand she's a non-network provider but if you were to see another doctor, it would be like starting all over again and you don't think it's fair. The Plan denied your request. National guidelines do not recommend annual pap smears after age 65 with previous normal smears. You have the new physician for a primary care physician. She is well trained in performing women care and Pap smears if the member desires continuity with a woman physician who she is familiar with. You went out on your own in 2018 and 2019 and with the understanding that your former gynecologist is out of 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 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. 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 (99213) to be provided by the out of network provider.