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

We decided that the Plan does not have to pre-approve Genvisc 850 25mg/2.5ml syringe 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 the plan requires a trial of Orthovisc and Monovisc, which was not documented in the medical records. There is no documentation provided indicating that these drugs 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 25mg/2.5ml syringe for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 9, 2020.
You asked the Plan to pay for the ambulance services. You say that this was a medical emergency and should be covered. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 9, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) (90471) rabies vaccine (90675) provided on November 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vaccination services. You say that this is an ED account and no authorization is needed. Please pay accordingly. 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 immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) (90471) rabies vaccine (90675) provided on November 14, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee brace (L1833) and a suspension sleeve (L2397) provided on October 9, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of DME may not contact an individual by telephone regarding the furnishing of a covered item to the individual except in cases outlined in the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee brace and a suspension sleeve have not been met. Specifically, the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a right knee brace (L1833) and a suspension sleeve (L2397) provided on October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole bone body scan.
You asked the Plan to pre-approve whole bone body scan. You say that this scan is needed because a Computed Tomography (CT) scan would not show any potential lesions. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because there is no clinical evidence to support medical necessity.
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 whole bone body scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical literature does not support this bone scan as the initial work-up for bony metastatic lesions. The literature supports whole body Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of whole bone body scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a whole bone body scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 6, 2020.
You asked the Plan to pay for the testing services. You say that the provider ordered the testing to determine if
there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The
Plan says to report comprehensive genomic profile testing, service providers should use CPT code 81479.
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 looked at the file and the rules. We find that the testing was not billed with one CPT code and one unit of
service for the procedure performed. 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 Guardant360 testing
provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne CDx testing (0037U) provided on February 14, 2020.
You asked the Plan to pay for FoundationOne CDx testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. To report a CGP service, test providers should use CPT code 81479 We find that CPT code 0037U is not supported in the medical record. Specifically, the testing at issue is a CGP service that should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of FoundationOne CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx testing (0037U) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on November 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services provided to the enrollee by an out-of-network
provider on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, A9277).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, A9277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown lengthening for tooth #21 (D4249).
You asked the Plan to pre-approve the crown lengthening. You say that the crown lengthening is medically
necessary. The Plan denied your request. The Plan says this is not 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, 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 a
crown lengthening for tooth #21 (D4249).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs may be met in the inpatient rehab facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program, or to prevent deterioration. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care, such as long term care. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve an MRI. You say that the enrollee's muscle weakness is highly suspicious for nerve root compression. The Plan denied your request. The Plan says the medical records do not show the enrollee's pain is not better after 6 weeks of conservative therapy.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI. Our physician reviewer found that the enrollee has a history of intermittent right knee pain over the past 6-7 years which worsened over the past 3 weeks, including lateral leg and foot numbness and tingling and weakness of right leg. A sensory exam showed decreased right leg tone, vibration, and sensation, no complaints of back pain or bowel/bladder control issues. The records did not describe any conservative efforts with physical therapy, anti-inflammatory drugs, or other modalities. There were no signs or symptoms suggestive of a red flag diagnosis to negate conservative efforts. Therefore, this request for MRI lumbar spine will be considered 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on November 10, 2020, and November 17, 2020.
You asked the Plan to pay for the personal care services. You say that the home health care services were medically necessary. You say that not having what is prescribed by your doctor puts you in imminent danger. You also say that you are currently disabled and on a limited income. The Plan denied your request. The Plan says that procedure codes with a status indicator of "I" are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that procedure code T1019 - personal care services, per 15 minutes - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pay for the personal care services provided on November 10, 2020, and November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 28, 29, and 31 and
pontics (D6240) for teeth # 29 and 30.

You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee does not need a
denture. The Plan denied your request. The Plan says the documentation fails to indicate or support any specific
physical or psychological condition(s) that preclude the use of a removable prosthesis.

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. The Plan covers the retainer
crowns and pontics when the services are medically necessary and reasonable.

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 retainer crowns and pontics. Our
reviewer says that these services are not medically reasonable and necessary for the enrollee. Our physician
reviewer found there has been no documentation provided that states there is any physical or neurological
disorder in this enrollee that would make the use of a removable appliance impossible. The treatment plan is
reasonable, extending the bridge to the next available unit, however the Plan has criteria that must be met. The
Policy restrictions on fixed prosthodontics does not allow for bridgework as a coverage matter without a
documented medical need where a bridge could not be used. Our reviewer also found that there would not be
coverage for the requested four unit bridge as all criteria have not been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the retainer crowns and pontics have not been met. Therefore, we decided that
the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 28, 29, and 31 and pontics (D6240)
for teeth # 29 and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and dental extraction to be performed by
an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you went to the regular dentist and they
were unable to perform the extraction and you need to see an oral surgeon. The Plan denied your request. The
Plan says the services are not covered when performed by an oral surgeon.
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.
Your supplemental dental benefits says the Plan only provides coverage for dental services when they are
performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
Therefore, we decided that the Plan does not have to pre-approve a consultation and dental extraction to be
performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided
July 22, 2020.
You asked the Plan to pay for the pneumatic compression device. You say that the device was medically
necessary. The Plan denied your request. The Plan says the documentation does not support the items billed.
The Plan must follow Medicare rules. Medicare rules say that pneumatic devices are covered only for the
treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers.
We looked at the file and Medicare rules. The documentation provided shows the enrollee had no ulcers on
physical exam. Based on this information, we decided that Medicare rules for coverage of the pneumatic
compression device have not been met. Therefore, we decided that the Plan does not have to pay for a
pneumatic compression device (E0651, E0667) provided July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206). We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and preventive procedure (D1999).
You asked the Plan to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and preventive procedure (D1999). You say that you believe these services should be covered because you thought you were seen by a different in-network provider. The Plan says that these services were rendered by a provider who has opted out of Medicare.
We decided that the Plan has to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206).
The Plan follows Medicare rules. Medicare rules say that an MA organization may make payment to a physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are provided to a beneficiary as a supplemental benefit consistent with 42 CFR section 422.102. The Plan says that you received these services from a Medicare opt out provider. The Plan verified with the provider that there was not a private contract between you and the provider regarding your financial responsibility for these services. There was no notice provided in the EOC that services with an opt out provider would not be covered for supplemental dental benefits. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206).
We also decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and preventive procedure (D1999).
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. These services are not listed as covered benefits in your EOC. The Plan also says that you were advised that you would be treated by this provider, and that the provider you thought you would see is never in the office on the particular day you went for your visit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and preventive procedure (D1999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on November 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate POS code. We looked at the file and Medicare rules. The claim was billed with POS code 31 for a skilled nursing facility and the enrollee was not under a SNF admission for the date of service at issue. 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 pay for the mobile x-ray services rendered on November 9, 2020.