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

We decided that the Plan does not have to pre-approveProlia for enrollee.You asked the Plan to pre-approvethese 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 does not have a history of osteoporotic fracture. There is no documentation that they have tried and failed the plan's required drug of zoledronic acid. The records do not support that the required drug would be less effective or contraindicated; therefore, Prolia is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia for enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ampyra tablets.
You asked the Plan to pre-approve Ampyra tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ampyra tablets are 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 Ampyra tablets.
Benefits for Ampyra tablets 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a pelvic ultrasound (76857) provided on May 3, 2019.You asked the Plan to pay for the pelvic ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of Ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (eg, for follicles).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 76857 is ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (eg, for follicles).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 pelvic ultrasound. Our reviewer says that the enrollee did not undergo an ultrasound of the pelvis/bladder. Our reviewer found the record indicates that the member underwent an AortaScan.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 pelvic ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a pelvic ultrasound (76857) provided on May 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy provided on May 23, 2019.
You asked the Plan to waive the copayment for the bone marrow biopsy. You say that you have never had a charge for bone marrow biopsies. You say that this was exactly the same procedure as your previous ones. The Plan denied your request. The Plan says the copayment applied correctly.
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 surgery services at an in-network outpatient hospital. You have been asked to pay a $200 copayment for the bone marrow biopsy. The bone marrow biopsy 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 for the bone marrow biopsy provided on May 23, 2019.
Your complaint about awful customer service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on September 6, 2019, September 13, 2019 and September 20, 2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you paid $30 for the first visit. You say that you were informed you did not have to pay for each visit. The Plan denied your request. The Plan says the copayments applied correctly.
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 $30 copayment for each specialist visit for Medicare-covered benefits. Covered services include medically necessary medical care or surgery services furnished in a physician's office. You have been asked to pay a total of $90 for the arthrocentesis.
Date of Service
Service
Standard Copayment
Member Liability
September 6, 2019
Arthrocentesis
$30
$30
September 13, 2019
Arthrocentesis
$30
$30
September 20, 2019
Arthrocentesis
$30
$30
TOTAL:
$90
The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" 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 the arthrocentesis provided on September 6, 2019, September 13, 2019 and September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a follow-up visit. You say that you would like a follow-up with the doctor
who did your implant. The Plan denied your request. The Plan says the provider also agrees that follow-up
visits can be provided in-network. The Plan says to contact your physician for a referral to a different 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 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
a follow-up visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration as this is the only drug that is effective for the member. The Plandenied your request. The Plan says the member has not tried and failed a trial of oral and intravenous bisphosphonate.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 Prolia. Our reviewer says that the enrollee previously had heartburn while taking oral alendronate. She has not tried an IV bisphosphonate. Our physician reviewer found the documentation does not support that an IV bisphosphonate would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome visits provided from April 25, 2017 to June 7, 2017.You asked the Plan to pay forhome visits. You say that these visits should be covered because in-network providers were not available for the services you needed.The Plan denied your request. The Plan says unauthorized out-of-network care is not covered.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home visits have not been met. Specifically, the information submitted does not contain medical records or receipts for the dates of service at issue. Without this information, medical necessity of the services cannot be established and payment cannot be made.Therefore, we decided that the Plan does not have to pay forhome visits provided from April 25, 2017 to June 7, 2017
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair (E0240) and a ramp (E1399).You asked the Plan to pre-approvethe bath/shower chair and ramp. You say that you have mobility issues caused by medical conditions requiring the use of a walker and the ramp request is needed to be able to leave your home independently.The Plan denied your request. The Plan says a bath/shower chair is considered hygiene equipment and a ramp for home access is considered a modification to the home and therefore are not covered benefits.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The items at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to thegeneral public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea bath/shower chair (E0240) and a ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge services rendered to the enrollee on August 16, 2019. 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 99239 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 discharge services rendered to the enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on September 11, 2019. 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 99153 is not supported. The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99153. This code has a PC/TC indicator of 3 and has no professional component. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you by a chiropractor on August 7, 2019 to October 16, 2019.You asked the Plan to pay forthese services. You say that you needed the services.The Plan denied your request. The Plan says the services are not covered.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 service at issue is not manual manipulation of the spine. The file shows that the provider submitted claims for procedure codes 97014 (electrical stimulation therapy), 97012 (mechanical traction therapy), 97140 (manual therapy techniques), 97535 (self-care management training), 72050 (cervical spine x-ray), and 72114 (lumbosacral spine x-ray). Therefore, we decided that the Plan does not have to pay forthe services rendered to you by a chiropractor on August 7, 2019 to October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetriamcinolone acetonide injections for the enrollee.You asked the Plan to pre-approvethese services. You say that  The Plan denied your request. The Plan says that this is 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 these services. Our reviewer says that that triamcinolone acetonide injections are not medically reasonable and necessary for the enrollee in this case. The memberhas a diagnosis of bilateral primary osteoarthritis of the knees. The member has been treated for chronic pain of the knees bilaterally due to osteoarthritis since 2016. The member has had numerous steroid injections to knees, physical therapy sessions, and home exercises for therapy. The member has not improved over the last few years and has progressed to needing hyaluronic acid injections. Over the counter medications, topical medications, physical therapy, and steroid injections have not improved the member's pain. Member has not tried Gabapentin and/or Lyrica. The member's last set of hyaluronic acid injections were done in September 2018, and the member had some improvement in the chronic knee pain. The member's last set of steroid injections were on March 10, 2020. The documentation indicates that the member had bilateral intraarticular triamcinolone injections on March 10, 2020. Past Hyaluronic Acid was in September 2018. However, it is unclear what benefit the member achieved from those injections since the only medical records are from 9/18/2018, 9/25/2018 and 3/10/2020 visits. The 3/10/2020 office visit notes did not discuss any benefit from the hyaluronic acid injections of 2018.The review has determined that the documentation does not support that the triamcinolone acetonide injections are medically reasonable and necessary for the patient. In addition, the documentation does not support that the triamcinolone acetonide injections are safe and effective for the patient. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.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-approvetriamcinolone acetonide injections for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 28, 2019.
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 codes 95937 and 95864 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 95864 is needle electromyography; 4 extremities with or without related paraspinal areas. We find that CPT codes 95937 and 95864 are not supported in the medical record. Specifically, the records do not show that neuromuscular junction testing was performed to support code 95937 or that needle electromyography was performed to support code 95864. 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 services rendered to the enrollee on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee has psychological barriers to using a traditional glucometer that requires finger sticks and seeing blood. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan. You asked the Plan to pre-approve Xifaxan. You say that you used this medication in March 2019 and it helped to relieve your symptoms. You say that your doctor requested this medication for you in December and it was denied. You also say that this medication works for you and you would like for it to be approved. The Plan denied your request. The Plan says the requested medication is not covered under your medical plan. 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 Xifaxan.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for services provided on August 11, 2017.You asked the Plan to pay for these services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the request was not received within the appropriate filing requirement.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to substantiate the denial. Therefore, we decided that the Plan has to pay for services provided on August 11, 2017.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 6, 2019 to September30, 2019.You asked the Plan to pay for the SNF services. You say that you are requesting reconsideration on the denial for coverage. You feel that it is appropriate for the plan to cover for the enrollee's brief stay.The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for SNF services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 6, 2019 to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim lower partial denture (D5821).
You asked the Plan to pre-approve an interim lower partial denture. You say that the service is necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim lower partial denture (D5821).