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

We decided that the Plan does not have to pre-approve Orthovisc injections.
You asked the Plan to pre-approve Orthovisc injections. You say that the requested Orthovisc injections are
medically necessary. The Plan denied your request. The Plan says the requested Orthovisc injections are not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Orthovisc injections. Our reviewer says
that the requested Orthovisc injections are not medically necessary. Our physician reviewer found this enrollee
presents with a history of chronic right knee pain with associated mechanical symptoms. Functional
improvement in gait is noted status post recent physical therapy. Clinical exam findings are consistent with
radiographic evidence of joint arthritis with collapse of both joint spaces, osteophytes throughout,
patellofemoral collapse with bone-on-bone appearance. Long-term conservative treatment has included activity
modification, oral and topical medications, physical therapy, and bracing. Under consideration is a request for a
series of Orthovisc injections for the right knee. There is evidence based medical literature that supports the use
of intra-articular hyaluronic acid injections in some patients. However, there is no evidence that the enrollee
had exhausted first-line treatment, including a corticosteroid injection. Therefore, the documentation does not
support that Orthovisc injections are medically reasonable and necessary or safe and effective for the treatment
of this enrollee's right knee condition 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 Orthovisc injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Orthovisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesecond facet joint blocks.You asked the Plan to pre-approverepeat facet joint blocks (64493, 64494, 64495). You say that the enrollee needs relief from low back pain.The Plan denied your request. The Plan says the request is not medically necessary because the enrollee's first injectionsdid not provide enough relief under Medicare rules.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. The percent of pain reliefdoes not meet the criteria for second facet joint blocks. Based on this information, we decided that Medicare rules for coverage of repeat facet joint blocks (64493, 64494, 64495) have not been met.Therefore, we decided that the Plan does not have to pre-approvesecond facet joint blocks.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting five
(5) more trips to last you to the end of the year because you have epilepsy and are not allowed to drive. The
Plan denied your request. The Plan says you exhausted 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 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. The 41st trip and
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional
routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered for
certain indications.
We looked at the file and Medicare rules. Continuous glucose monitors are only covered you are insulin-treated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin
infusion (CSII) pump. Review of the file shows that you only take on insulin injection a day. Based on this
information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on February 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95937 and 95940 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95940 is continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure).We find that CPT codes 95937 and 95940 are not supported in the medical record. Specifically, there is no documentation of neuromuscular junction testing to support code 95937 or continuous intraoperative neurophysiology monitoring to support code 95940. 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 forthe testing services rendered on February 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
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 a history of chronic low back pain. The Intracept procedure is considered experimental for the treatment of back pain. More research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these services are provided in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/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 lab work provided on June 29, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous tests (95004) and intracutaneous tests (95025)
provided on April 28, 2020.
You asked the Plan to pay for percutaneous tests and intracutaneous tests. You say that this is supported in the
records. The Plan denied your request. The Plan says these tests are not documented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95004 is percutaneous tests (scratch, puncture, prick)
with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of
tests; and 95025 is intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction,
including test interpretation and report, specify number of tests.
We find that CPT codes 95004 and 95025 are not supported in the medical record. Specifically, there is not
documentation of these tests being performed in the submitted medical records. Based on this information, we
decided that Medicare rules for coverage of percutaneous tests and intracutaneous tests have not been met.
Therefore, we decided that the Plan does not have to pay for percutaneous tests (95004) and intracutaneous
tests (95025) provided on April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on July 1, 2020.You asked the Plan to pay forthe dental service. You say that your benefit booklet clearly indicates routine cleanings are covered once every 6 months and you pay $0.The Plan denied your request. The Plan says prophylaxis is not listed as a covered service under your specific plan. The Plan also says your specific plan does not cover preventive and diagnostic dental services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, preventive and diagnostic dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on July 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99282 and related
services coded 80048, 81001, 85025, 96365, and J0696 provided on June 5, 2020.
You asked the Plan to pay for the emergency department visit and related services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the claims were billed
incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 99282, 80048, 81001, 85025, 96365, and J0696 are not supported in the medical
record. Specifically, Billed HCPCS code 93005 is a type STV packaged procedure and was billed with HCPCS
code 99285 that denied with reason medical visit on the same day as a type T or S procedure without modifier
25. This denial is generated if any E&M code that occurs on a day with a type "T" or "S" procedure does not
have a modifier of 25. All the remaining lines were denied to correct the OCE 21 denial. Based on this
information, we decided that Medicare rules for coverage of the emergency department visit and related
services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency
department visit coded 99282 and related services coded 80048, 81001, 85025, 96365, and J0696 provided on
June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D4263) and guided tissue regeneration (D4266) provided on June 5, 2020.
You asked the Plan to pay for the bone replacement graft (D4263) and guided tissue regeneration (D4266). You say that the plan indicates you should be covered at 50% for periodontics and oral surgery. You say that you shouldn't have to pay this amount. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D4263) and guided tissue regeneration (D4266) provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on January 14, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component testresults and was not billed as one test under code 81479.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a hip replacement. He was also treated for a heart attack after surgery.  Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora tangential biopsy of skin provided on May 21, 2020.You asked the Plan to waive the copayment fora tangential biopsy of skin. You say that you disagree with the surgery charges.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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a tangential biopsy of skin on May 21, 2020 at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $191.86, which is less than the $200 copayment. You have been asked to pay $191.86for a tangential biopsy of skin. A tangential biopsy of skin falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora tangential biopsy of skin provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided by a participating provider on August 6, 2020.
You asked the Plan to waive the copayment for an eye exam. You say that you paid $20. You say that you do not feel like you owe this additional $20. The Plan denied your request. The Plan says the correct copayment has 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 $40 copayment for vision care/eye exam. You have been asked to pay a $40 copayment for an eye exam. The correct copayment has been applied to the eye exam that was provided. An eye exam falls within the vision care/eye exam 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 an eye exam provided by a participating provider on August 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three (3) additional physical therapy services.
You asked the Plan to pre-approve three (3) additional physical therapy services.. You say that the services are necessary. The Plan denied your request. The Plan says the records sent do not support the request for treatment.
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 three (3) additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy for this condition and it does not appear that the patient requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been authorized additional sessions to review an independent exercise program. The specialized skill, knowledge and judgment
of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of three (3) additional physical therapy services. have not been met. Therefore, we decided that the Plan does not have to pre-approve three (3) additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for self-care/home management training providedon June 29, 2020.You asked the Plan to pay for the self-care/home management training. The Plan denied your request. The Plan says 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.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 self-care/home management training provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery you had at an ambulatory surgical center.

You asked the Plan to waive the copayment forthe outpatient surgery. You say that you had this same procedure at a different facility and didn't have to pay a copayment.The Plan denied your request. The Plan says you were charged this copayment correctly.  

The Plan says that copayments apply based on the type of facility where the services are rendered.  You had these services at an ambulatory surgical center, so the copayment is correct.

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 $325 copayment for outpatient surgery in an ambulatory surgical center.

 You have been asked to pay a $325 copayment for the outpatient surgery. 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 forthe outpatient surgery you had at an ambulatory surgical center.