Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for physical therapy provided by a participating provider on November 20, 2020, to December 7, 2020.

You asked the Plan to waive the co-payment for physical therapy. You say that physical therapy is required after a knee replacement. You say that these co-payments should be waived. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 co-payment for outpatient rehabilitation services/in-network.

You have been asked to pay a $40 co-payment for physical therapy. The total amount you are being asked to pay is $320 ($40 x 8 visits = $320). The correct co-payment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/in-network 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 co-payment for physical therapy provided by a participating provider on November 20, 2020, to December 7, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Premarin Tab

You asked the Plan to pre-approve Premarin Tab. You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B
benefit.

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 Premarin Tab.

Benefits for Premarin Tab 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4260, D4263).

You asked the Plan to pre-approve the services. You say that this is medically necessary, as you are under a lot of pain. The Plan denied your request. The Plan says these services are excluded.

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 dental services (D4260, D4263). 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 dental services (D4260, D4263).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. Current evidence and medical guidelines do not support the use of the Superion spacer over the gold standard of a lumbar laminectomy. The services are considered experimental in nature and not 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-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lisinopril, 20 mg tablet.

You asked the Plan to pre-approve lisinopril. You say that the enrollee needs to continue to receive this medication. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 lisinopril, 20 mg tablet.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent syringe, 300 mg/2 ml.

You asked the Plan to pre-approve Dupixent. You say that the medication has provided significant improvement for the enrollee's condition. You also say that it has improved the enrollee's symptoms. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 Dupixent syringe, 300 mg/2 ml.

Benefits for Dupixent 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana 15mcg/2ml solution 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 a step therapy exception cannot 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 there is no trial and failure of the plan's required drug (Perforomist). There is no documentation provided indicating that this drug 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 Brovana 15mcg/2ml solution for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational multifocal lenses (V2786 x2).

You asked the Plan to pay for occupational multifocal lenses. You say that you did not understand what was covered. The Plan denied your request. The Plan says the items at issue are not a covered service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. Though the Plan offers a vision 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 occupational multifocal lenses (V2786 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for [complete description of item or service at issue, e.g. at issue
is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]

You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"].
You say that you would like reconsideration based on the records submitted. The Plan denied your request. The
Plan says it is not appropriate to report the 59 and XS modifiers together.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met.
Specifically, the XS modifier is a more selective version of the 59 modifier, therefore it is inappropriate to bill
them together. Therefore, we decided that the Plan does not have to pay for [complete description of item or
service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the wound therapy pump provided on October 26, 2020 and October 27, 2020.

You asked the Plan to reduce the coinsurance for the wound therapy pump. You say that the device was not able to be used and the device was discontinued. You say that the charges should be reduced to reflect three days of use. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered item from an in-network provider.

You have been asked to pay $188.01, which is 20% of the allowed amount for the wound therapy pump. The allowed amount is $940.07 (20% x $940.07 = $188.01). The wound therapy pump falls within the "Durable medical equipment (DME) and related supplies" 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 reduce the coinsurance for the wound therapy pump provided on October 26, 2020 and October 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on April 8, 2020, to July 1, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient rehabilitation services/in-network. 

You have been asked to pay a $30 copayment for each physical therapy. The total amount you are being asked to pay is $570 ($30 x 19 visits = $570). Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on April 8, 2020, to July 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.

You asked the Plan to pre-approve Reblozyl. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not supported for the enrollee's diagnosis.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Reblozyl. Our reviewer says that the
requested Reblozyl is not medically reasonable and necessary in this case. Our physician reviewer found
Reblozyl is FDA-approved for beta-thalassemia, and the enrollee has alpha-thalassemia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have
to pre-approve Reblozyl.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine Pamoate 50mg tablets (J8499).

You asked the Plan to pre-approve Hydroxyzine Pamoate. You say that this medication is medically necessary. The Plan denied your request. The Plan says Hydroxyzine Pamoate is not eligible for coverage under the Part B medical benefit for the enrollee's diagnosis.

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 Hydroxyzine Pamoate 50mg tablets (J8499).

Benefits for Hydroxyzine Pamoate 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically
necessary. The Plan denied your request. The Plan says you can receive same services at the current level of
care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 15, 2019.

You asked the Plan to pay for the services provided. You say that the procedure notes support necessary clinical criteria. The Plan denied your request. The Plan says anesthesia for routine pain procedures is warranted only in unusual circumstances.

The Plan must follow Medicare rules. Medicare rules say that documentation must clearly establish the need for sedation in the specific enrollee. 

We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the use of anesthesia was necessary for the enrollee's lumbar injection. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).

You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied
your request. The Plan says the documentation shows the drug is being provided by a pharmacy. Part B
coverage is not available.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for collection of venous blood by venipuncture (36415) comprehensive metabolic panel (80053) complete blood count (85027) chemotherapy administration, subcutaneous or intramuscular (96402) provided on January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the chemotherapy services. You say that you are requesting a reconsideration of the denial, review of the medical records and approval of the services provided. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 collection of venous blood by venipuncture (36415) comprehensive metabolic panel (80053) complete blood count (85027) chemotherapy administration, subcutaneous or intramuscular (96402) provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).

You asked the Plan to pre-approve Supartz (J7321). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had
a contraindication or intolerance to Monovisc.

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 Supartz (J7321). Our reviewer says that
the drug is not reasonable and medically necessary. Our physician reviewer found per the provider the patient
has previously been treated with Supartz and received excellent results with pain relief for about a year. The
enrollee did try Orthovisc in February and March of this year and her pain has already returned. There is no
documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely
have adverse effects for the 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 Supartz (J7321) have not been met. Therefore, we decided that the Plan does
not have to pre-approve Supartz (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on November 16, 2020.

You asked the Plan to pay for the dental service. You say that your dentist assured you that this was the only way to save this tooth. You say that this was surely preventive care so that you can eat and chew and smile. The Plan denied your request. The Plan says root canal is not listed as a covered service.

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, root canal is not among those covered under this benefit. The record shows that you did not purchase the optional supplemental dental rider. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical assistant services (CPT 29807, CPT 29822, CPT 29826) provided to the enrollee on July 27, 2020.

You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says this is unable to be approved.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 29807. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.

Additionally, our doctor found that there is no evidence of surgical assistance on CPT 29822. A review of the operative report (as dictated) does not corroborate such assistance on CPT 29822 as having been performed.

Additionally, CPT 29826 is an add-on code that must have an approved primary procedure to be paid. The primary procedure for this code is 29807, which was denied as it does not require a surgical assistant. 

Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical assistant services (CPT 29807, CPT 29822, CPT 29826) provided to the enrollee on July 27, 2020.