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

We decided that the Plan does not have to pay for the eye refraction provided on January 25, 2021.
You asked the Plan to pay for the eye refraction. You say that the provider is a contract provider therefore the claim should be paid. The Plan denied your request. The Plan says the refraction was billed as a medical diagnosis therefore not a routine refraction provided by the preferred provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions during a routine exam when provided by the preferred provider. We looked at the file and the Plan's rules. The refraction was not a routine refraction nor provided by the Plan preferred provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on December 7, 2020 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that this provider is showing as in-network in the Plan's provider directory. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that this provider is allowed to bill the difference of the allowed amount and their billed amount to you.

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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on December 7, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve endodontic therapy (root canal treatment) for teeth #23 and #27.
You asked the Plan to pre-approve endodontic therapy. You say that you are in extreme pain and would like it
to go away before it gets worse. The Plan denied your request. The Plan says that the denial of authorization for
these services is correct, because your teeth are not healthy enough to support root canal treatment with any
long-term outcome.
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 endodontic
therapy 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 endodontic therapy. Our reviewer says
that you meet the criteria for the requested root canal treatments. Our physician reviewer found at review of
your dental record and radiographs indicates that the bone support appears adequate and the restoration of the
carious and fractured portions of the coronal structure of these teeth would restore them to adequate function.
Therefore, this is medically reasonable and necessary.
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 endodontic therapy have been met. Therefore, we decided that the Plan has to
pre-approve endodontic therapy (root canal treatment) for teeth #23 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on February 15, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 6, 2020.

You asked the Plan to waive the copayment for laboratory services. You say that you received the laboratory services as part of your annual physician and should not be responsible for the 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 $10 copayment for laboratory tests. 

You received laboratory services on November 6, 2020. Laboratory services are not included in annual wellness exams and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $8.46, which is less than the $10 copayment. 

You have been asked to pay $8.46 for laboratory services. Laboratory services fall 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 laboratory services provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
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.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. She has not tried and failed the Plan's required drugs, Euflexxa, Supartz FX, Durolane, or Gelsyn-3. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair including delivery charge provided on September 11, 2020.
You asked the Plan to pay for a power wheelchair and delivery charge. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The rules also state that payment for delivery of DME is generally included in the fee schedule allowance for the item. The record does not contain a valid physician order nor home assessment for the supplies provided in this case.
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Delivery charges are not a Medicare benefit. Therefore, we decided that the Plan does not have to pay for a power wheelchair including delivery charge provided on September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs.
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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the services are not medically necessary or reasonable.

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 patient does not require treatment by multiple therapies and there are no complex
nursing or rehabilitation needs.

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. Specifically, medically necessary services are available at a lower level of care. This mean admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on December 21, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says refractions are only covered if they are routine and performed by the Plan's vision care provider.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on December 21, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bypass graft, with other than vein; femoral-popliteal (35656), thromboendarterectomy, including patch graft, if performed; superficial femoral artery (35302), if performed; popliteal artery (35303).
You asked the Plan to pre-approve bypass graft, with other than vein; femoral-popliteal (35656), thromboendarterectomy, including patch graft, if performed; superficial femoral artery, including patch graft (35302), and thromboendarterectomy, including patch graft, if performed; popliteal artery (35303). You say that the enrollee needs these procedures. The Plan denied your request. The Plan says that medical records do not say that there were any blockages, blood flow problems, or pain.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 bypass graft, with other than vein; femoral-popliteal (35656), thromboendarterectomy, including patch graft, if performed; superficial femoral artery, including patch graft (35302), and thromboendarterectomy, including patch graft, if performed; popliteal artery (35303). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has an adequate femoral pulse, weak popliteal pulse and absent dorsalis pedis and posterior tibial pulse on examination. The record indicates the enrollee has left leg rest pain. The record indicates that atherectomy of the left leg was attempted May 2021. The record is sufficient to support the medical necessity and reasonableness of the requested service. The elements of the coverage determination are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bypass graft, with other than vein; femoral-popliteal (35656), thromboendarterectomy, including patch graft, if performed; superficial femoral artery, including patch graft (35302), and thromboendarterectomy, including patch graft, if performed; popliteal artery (35303) have been met. Therefore, we decided that the Plan has to pre-approve bypass graft, with other than vein; femoral-popliteal (35656), thromboendarterectomy, including patch graft, if performed; superficial femoral artery (35302), if performed; popliteal artery (35303).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable nerve stimulator.
You asked the Plan to pre-approve the requested services. You say that the enrollee is likely to obtain
significant therapeutic benefit from the treatment. The Plan denied your request. The Plan says the service is
not a covered 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. Acupuncture for stimulation of auricular points is not a covered
Medicare benefit. 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 pre-approve an implantable nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider on December 2, 2020.

You asked the Plan to pay for wound debridement. You say that the Plan did not have all the pertinent information at the time of initial denial. You say that you submitted additional documentation supporting the appeal and coverage should be allowed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 wound debridement provided by an out-of-network provider on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 20, 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 procedure code 15734 is 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 15734 and 15734-51-76 is muscle, myocutaneous, or
fasciocutaneous flap; trunk.

We find that CPT codes 15734 and 15734-51-76 are not supported in the medical record. Specifically, the
operative report does not contain documentation of a muscle, myocutaneous, or fasciocutaneous flap of the
trunk. 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 surgical services rendered on November
20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Iluvien 0.19mg intravitreal implant (J7313).
You asked the Plan to pre-approve the Iluvien 0.19mg intravitreal implant. You say that this drug has been proven to reduce most swelling in the macula after insertion. The Plan denied your request. The Plan says the documentation does not show that the enrollee has tried a generic intravitreal steroid for their current condition.
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 Iluvien 0.19mg intravitreal implant. Our reviewer says that an Iluvien 0.19 mg intravitreal implant (J7313) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed a generic intravitreal steroid for her current condition. Our reviewer also found that there is no indication that the Plan's required drug 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 Iluvien 0.19mg intravitreal implant have not been met. Therefore, we decided that the Plan does not have to pre-approve an Iluvien 0.19mg intravitreal implant (J7313).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health nursing visits and 6 additional
home health aide visits.
You asked the Plan to pre-approve 6 additional home health nursing visits and 6 additional home health aide
visits. You say that the 6 additional home health nursing visits and 6 additional home health aide visits are
medically necessary. The Plan denied your request. The Plan says the 6 additional home health nursing visits
and 6 additional home health aide visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 6 additional home health nursing visits
and 6 additional home health aide visits. Our reviewer says that the 6 additional home health nursing visits and
6 additional home health aide visits are not medically necessary. Our physician reviewer found based on the
documentation provided, the enrollee does not have documented skilled nursing needs. Therefore, the
requested home health visits are not shown to be medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 6 additional home health nursing visits and 6 additional home health aide visits
have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health
nursing visits and 6 additional home health aide visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on July 25, 2020 to August 5, 2020.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.

The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on July 25, 2020 to August 5, 2020.