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

We decided that the Plan does not have to pay for nail debridement (11721) provided from March 6, 2019 to May 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for nail debridement. You say that you would like the claims to be reconsidered for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent or emergent and could be provided 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 nail debridement (11721) provided from March 6, 2019 to May 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the records submitted show that the enrollee meets
the criteria. The Plan denied your request. The Plan says there is no evidence that the criteria for the CGM are
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and does not use insulin with at least three daily injections. There is
no mention in any of the records provided how often the enrollee is testing their blood sugar. The medication
list provided in all the records also does not include any mention of insulin, or that insulin is injected at least
three times daily. Based on this information, we decided that Medicare rules for coverage of the CGM have not
been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and two core buildups, including any pins when required.
You asked the Plan to pre-approve the crown and core buildups. You say that you need these services to be approved. The Plan denied your request. The Plan says your crown benefit has been exhausted. The Plan also says that core buildup 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, core buildups are not among those covered under this benefit. The Plan contract says that crowns are limited to one procedure per calendar year. The record shows that you were approved for a crown for tooth #4 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown and two core buildups, including any pins when required.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided from September 14, 2020, to September 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The requested outpatient services were billed on an inpatient claim. It is inappropriate to bill outpatient services on an inpatient claim. The documentation submitted by the non-contract provider does not show that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from September 14, 2020, to September 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc (J7325). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc.
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 Synvisc (J7325). Our reviewer says that the drug is not medically necessary. Our physician reviewer found the patient has not tried and failed the required drug(s). 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 Synvisc (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.

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 to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a Medicare-covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

Medicare does not consider this item to be medically necessary. 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 a fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation
(D0120) rendered by the OON provider on October 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services provided are not payable as they
were rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. 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 the dental cleaning (D1110) and the periodic oral evaluation (D0120) rendered by
the OON provider on October 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linezolid Tab.
You asked the Plan to pre-approve Linezolid Tab. You say that you want the enrollee 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 Linezolid Tab.
Benefits for Linezolid 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.

You asked the Plan to pre-approve Eylea. You say that you would like this covered. The Plan denied your request. The Plan says that you have not tried and failed the preferred step therapy drug.

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 Eylea. Our reviewer says that Eylea is not medically reasonable and necessary. Your prescriber has indicated there is no contraindication to the plan's required step therapy drug, Avastin. Our physician reviewer found that your condition does not meet step therapy criteria for Eylea. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for mitral valve replacement and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received on September 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received on September 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical transport provided to the enrollee on September 30, 2020.
You asked the Plan to pay for the medical transport. You say that the treating physician recommended that the enrollee should be close to family members who could better monitor their care. The Plan denied your request. The Plan says the services are not covered.
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 service that was performed is not a Medicare covered service and is not covered by the Plan. Additionally, an authorization was requested for these services on September 30, 2020, by the enrollee's treating physician and was denied on October 1, 2020, because there were other skilled-nursing facilities in the Plan's service area that could have provided the same level of care needed without needing to go out of state. Therefore, we decided that the Plan does not have to pay for the medical transport provided to the enrollee on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for LDCT (CPT code G0297) provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the LDCT. You say that the services were necessary. The Plan denied your request. The Plan says the enrollee exhausted their benefit.
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 LDCT have not been met. The enrollee exhausted their benefit because they had the same service on May 3, 2019. If the enrollee was symptomatic this would no longer be considered a preventive service and would need to be billed using a different code. The enrollee had this service done twice within a year. The plan benefits say they will cover a Screening for Lung Cancer with LDCT every twelve (12) months for qualified individuals. Therefore, we decided that the Plan does not have to pay for LDCT (CPT code G0297) provided to the enrollee on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit (Q5106). You say that the enrollee needs this drug. The Plan denied your request. The Plan says the request does not meet Part B coverage criteria.
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 Retacrit (Q5106). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found in controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoietin stimulating agents to target a hemoglobin level of greater than 11 g/dL. On last check the enrollee's hemoglobin was 11.7 which is considered too high to receive Retacrit. The service 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 Retacrit (Q5106) have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids you received on October 27, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the benefit limit has been paid.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to a $500 coverage limit every three years. We looked at the file and the Plan's rules. The records show that the Plan paid $200 toward the hearing aids. As $300 was previously paid by the Plan in 2020 for hearing aid services, this means that a total of $500 was paid for the 2020 plan year. You are responsible to pay any costs over the $500 benefit limit. Therefore, we decided that the Plan does not have to pay for the hearing aids you received on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on October 21, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you thought that the charges would be
covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.
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 $200
copayment for CT scans.
You have been asked to pay the allowed amount of $189.03, which is less than the $200 copayment for a CT
scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 waive the copayment for a CT scan provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L2397, L1833).

You asked the Plan to pay for a knee orthosis. You say that this is supported in the records. The Plan denied your request. The Plan says the enrollee has not seen the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L2397, L1833).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization (37223) and angiography (75736) provided on September 24, 2020.
You asked the Plan to pay for the revascularization and angiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 asked our coder 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 revascularization and angiography. Our reviewer says that CPT code 37223 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to support a Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) being performed on September 24, 2020, therefore this service cannot be verified. Our reviewer found CPT code 75736 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to verify that an Angiography, pelvic, selective or supraselective, radiological supervision and interpretation was performed on September 24, 2020 therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the revascularization and angiography have not been met. Therefore, we decided that the Plan does not have to pay for revascularization (37223) and angiography (75736) provided on September 24, 2020.