Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX.
You asked the Plan to pre-approve Supartz FX. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Gel-One, Orthovisc, Synvisc, Synvisc-One, or Visco-3 before it will approve Supartz FX.
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 FX. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Supartz FX. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Gel-One, Orthovisc, Synvisc, Synvisc-One, or Visco-3. The documentation does not show that these drugs would likely be less effective and/or 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 FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dialysis services provided November 4, 2019 to December 29, 2019.
You asked the Plan to waive the copayment for the dialysis services. You say that this amount is impossible for you to pay as your social security only sends your $1,278 per month. You ask that the plan disallow these provider charges. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
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% of the total cost for Medicare covered dialysis services. You have been asked to pay $1,731.60 for the dialysis services. The dialysis services fall within the Services to
treat kidney disease 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 dialysis services provided November 4, 2019 to December 29, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller and related accessories 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve an expandable controller and related accessories. You say that it is 
medically necessary for the enrollee to have an expandable controller. The Plan denied your request. The Plan 
says the criteria for coverage of this equipment have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is medically necessary when 
it is used for an indication listed 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 an expandable controller and related 
accessories. Our reviewer says that the requested expandable controller is not medically necessary for the 
enrollee's condition. Our physician reviewer found the documentation does not reveal that the patient requires 
other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, 
head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not 
need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for 
alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer 
through the chair's drive control), or an attendant control. The patient's strength and function in the upper 
extremities with the ability to independently dress and eat indicates that the patient can control any power 
options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related accessories (E2377, 
E2313, E2311).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transportation trip that exceeds 50 miles.
You asked the Plan to pre-approve a routine transportation trip that exceeds 50 miles. You say that you need a longer trip to see your eye doctor. The Plan denied your request. The Plan says the requested trip exceeds the maximum mileage of your benefit.
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 routine transportation when each trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine transportation trip that exceeds 50 miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are not medically necessary.
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 that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that is not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for Epifix services. We decided that the Plan does not have to pay for the office visit.
You asked the Plan to pay for Epifix services. You say that you cannot see the provider until the amount is paid. The Plan says that anatomical modifiers should not be appended to the denied code.
We decided that the Plan has to pay for the Epifix services (Code Q4186).
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.
The Epifix services at issue were provided by a contract provider. The file does not show that the Plan provided notice that the service would not be covered. Under Medicare rules, this means the service at issue is considered approved by the Plan. This billing discrepancy is between the provider and the Plan. Therefore, we decided that the Plan has to pay for the Epifix services (Code Q4186) on July 8, 2020.
We also decided that the Plan does not have to further pay for the office visit.
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 10% coinsurance for physician services.
You have been asked to pay a 10% coinsurance for the office visit. The visit falls within the physician services 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 further pay for the office visit provided on July 8, 2020.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40 additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need to get to the doctor's office. The 
Plan denied your request. The Plan says the benefit plan does not cover more than 40 one-way trips per year, 
no matter what reason they are being asked for. 
 
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 40 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 40 additional non-emergent transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on February 18, 2021.
You asked the Plan to pay for incomplete endodontic therapy. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for incomplete endodontic therapy (D3332) provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transport chair rental provided on January 1, 2021 to February 1, 2021 by an out-of-network provider.
You asked the Plan to pay for the transport chair rental. You say that you received a broken wheelchair and it was unusable. The Plan denied your request. The Plan says they cannot pay the claim because the supplier is not a network provider.
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 item at issue in this appeal. The Plan did not pre-approve the item at
issue. We found no exception that would require the Plan to pay for the item. Therefore, we decided that the Plan does not have to pay for the transport chair rental provided on January 1, 2021 to February 1, 2021 by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional physical therapy visits.
You asked the Plan to pre-approve 14 additional physical therapy visits. You say that you tore your rotator cuff and the doctor said you might need therapy for a year. You say that you still need a lot of help to fully recover and are concerned about losing the progress you have made so far. The Plan denied your request. The Plan says the medical necessity of additional visits cannot be determined without an updated reassessment.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 14 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our reviewer says that updated records are not available indicating your progress with the ten additional therapy visits that have been approved. Our physician reviewer found that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 14 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, multiple power 
actuator (electrical connection), and joystick. 
 
You asked the Plan to pre-approve power wheelchair components. You say that the enrollee relies on a custom 
wheelchair to live independently. The Plan denied your request. The Plan says the denial of authorization for 
these items is correct, because the joystick is already included in the requested power wheelchair and the 
enrollee is able to control the wheelchair's power options using their own switches.  
 
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 power wheelchair components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the available records do not document that the enrollee's upper extremity 
strength and function are inadequate to operate the power wheelchair's options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller, harness, multiple power actuator (electrical 
connection), and joystick.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH would be the 
optimal level of care for the enrollee at this time. The Plan denied your request. The Plan says the enrollee is 
receiving adequate care in the current setting and is not yet clinically stable for transfer to any other facility. 
 
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 enrollee was admitted to the acute care hospital on 7/2/21 for a splenic laceration 
following a fall. On 7/21/21, an exploratory laparotomy was performed, with a splenectomy and placement of 
bilateral chest tubes. The postoperative course was complicated by myocardial infarction and acute kidney 
injury. One of the chest tubes has been removed. On 8/2/21, the drainage from the left chest tube was 500 mL, 
necessitating continuation of the tube.

Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. 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. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided to the enrollee on December 
17, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the outpatient services. You say that the facility provides care at the direction of 
the attending physician and, in turn, request reimbursement for the services rendered. The Plan denied your 
request. The Plan says this provider is out-of-network, the services were not referred by a network provider, 
and the services were not urgent or emergent, nor were they approved in advance.

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 outpatient services provided to the enrollee on 
December 17, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62323 provided on February 10,
2021 and March 10, 2021.
You asked the Plan to pay for the injection services. You say that you feel this claim should be paid. The Plan
denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 62323
for the injection services has a bundled relationship with code 01936 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the injection services coded 62323 provided
on February 10, 2021 and March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation regarding cancer treatment with an out-of-network provider.
You asked the Plan to pre-approve a consultation regarding cancer treatment. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 provider at issue in this case is not a network provider with the Plan. 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 consultation on cancer treatment. Our reviewer says that the requested service is not reasonable or medically necessary. Our physician reviewer found that you are seeking a second opinion at an out-of-network cancer care provider. You have an unresectable non-small cell squamous cell lung cancer due to the extent of the tumor. There are in-network physicians available for a second opinion. There is
no documentation provided indicating why an out-of-network provider would be necessary over those available
within network.
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 consultation on cancer treatment have not been met. 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 a consultation regarding cancer treatment. Therefore, we decided that the Plan
does not have to pre-approve a consultation regarding cancer treatment with an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the office visit (99214) 
provided on April 19, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $35 
copayment for each in-person specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist visit provided. 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 issue reimbursement of the copayment for the office visit (99214) 
provided on April 19, 2021.