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

We decided that the Plan does not have to pre-approve a new patient office visit (99203) and follow-up established patient visits (99213) to be provided by an out of network provider.
You asked the Plan to pre-approve office visits. You say that this is the closest aquatic physical therapy from your home. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 new patient office visit (99203) and follow-up established patient visits (99213) to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require extensive rehab therapies to regain strength and functional quality of life. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee was admitted to the acute hospital for a pulmonary embolism, sepsis, large abdominal wall abscess, and acute respiratory failure. There are no noted complex wounds. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that She requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and caries risk assessment and documentation (D0602) provided on January 28, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and caries risk assessment and documentation. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that services rendered by a provider who is not in-network with the Plan are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and caries risk assessment and documentation (D0602) provided on January 28, 2021 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (S1015) and the infection control supplies, not otherwise specified (S8301) provided on August 10, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services in this case have a status code "I." The Plan says that this means that the service is not valid for Medicare purposes. The Plan also says that these services are not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that procedure code S1015 - intravenous (IV) tubing extension set - and procedure code S8301 - infection control supplies, not otherwise specified - have a Status Code of "I" and therefore are not payable by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (S1015) and the infection control supplies, not otherwise specified (S8301) provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 5, 2020.
You asked the Plan to reimburse you for the dental services. You say that when you signed up for coverage, you were told by your agent that you would be reimbursed for any dental expense incurred. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider who has opted out of Medicare.
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 dental services when the services are medically necessary and reasonable. 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, dental services performed by a dentist who has opted out of Medicare are not payable. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 5, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.

You asked the Plan to pre-approve Evenity. You say that this request is medically necessary. The Plan denied
your request. The Plan says step therapy criteria have not been met for the requested drug.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that step
therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Prolia or Reclast
(zoledronic acid) before they will approve the requested drug. In this case, the patient has not tried and failed
the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would
likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve intensity-modulated radiation therapy.

You asked the Plan to pre-approve intensity-modulated radiation therapy. You say that this request is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage
have not been met.

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. In this case, we requested you reach out to the enrollee's provider for medical
records to address the coverage criteria. No medical records were provided in the case file. We did not receive
a response to our request for information. Therefore, we decided that the Plan has to pre-approve intensity modulated
radiation therapy.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Prolia. Our reviewer says that the step therapy criteria have not been met in this case. Our physician reviewer found that in this case, the records indicate that the enrollee has age related osteoporosis without pathologic fracture. The requested medication is a new start. The enrollee has not tried and failed, nor has the prescriber indicated that the enrollee is unable to use zoledronic acid. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions January 18, 2021.
You asked the Plan to pay for the extractions. You say that your contract does not state that there are specific services that are not reimbursable. The Plan denied your request. The Plan says your extractions benefit has been satisfied and the frequency limitation has been exceeded.
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 limited to two extractions per plan year, which are covered at 50%. The record shows that you received 11 extractions on January 18, 2021, two of which were covered at the in-network rate of 50% by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the extractions January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #19.
You asked the Plan to pre-approve the crown. You say that a crown is medically necessary for this tooth. The Plan denied your request. The Plan says there is not enough bone support, and the tooth will not last long with a crown on it.
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 crown when the services are medically necessary and reasonable. The Plan criteria also states that the enrollee must be free from active and advanced periodontal disease. 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 crown. Our reviewer says that the criteria for coverage of a crown have not been met. Our physician reviewer found that the tooth in question appears to have recurrent decay as well as significant bone loss on the distal root and some in the furcation area as well. Tooth #19 exhibits severe periodontal breakdown. It is not documented that you have been undergoing periodontal treatment and that the progression of the disease has been stopped or slowed. Where there is no active treatment and maintenance of periodontal disease, there is a poor prognosis for the long-term retention of a tooth. Given the presentation of the tooth and periodontal support, and lack of documented periodontal treatment, there is no current medical necessity for a new crown on #19. 
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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient hospital care following the enrollee's surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient medical care following the elective surgery is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 67-year-old female with a large rotator cuff tear who has been approved for right reverse total shoulder arthroplasty. The review indicates that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has lost strength in his legs and is unable to walk. The Plan denied your request. The Plan says the denial of authorization for inpatient hospital level of care is correct, because the enrollee can be treated in observation.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our physician reviewer found there was no acute condition that warranted any acute care services.

The enrollee warranted close observation and further evaluation as well as arrangement for long-term placement services due to the enrollee's spouse not being able to take care of him; however, observation level of care would have been more appropriate for this clinical presentation. It was not expected that the enrollee would require hospital services that would likely span at least 2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection.

You asked the Plan to pre-approve chemodenervation of muscle(s) (64615) and injection,
OnabotulinumtoxinA, 1 unit (J0585). You say that you need the Botox treatment because of a childhood injury.
The Plan denied your request. The Plan says the Botox is for symmetry not muscle spasm conditions of the
face.

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 chemodenervation of muscle(s) (64615)
and injection, OnabotulinumtoxinA, 1 unit (J0585). Our reviewer says that the injection is not medically
reasonable and necessary. Our physician reviewer found there is no documentation that the Botox is medically
reasonable and necessary for the enrollee's condition as defined by Medicare criteria. The provided medical
records indicate the Botox is being used "primarily on the left side for symmetry purposes" with no mention of
spasticity or functional impairment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of chemodenervation of muscle(s) (64615) and injection, OnabotulinumtoxinA, 1
unit (J0585) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Botox
injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 8, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you are receiving an ongoing treatment and feel that you should not owe a copayment every time. 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 $25 copayment for each specialist visit. You have been asked to pay a $25 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483).
You asked the Plan to pre-approve a high frequency chest wall oscillation device. You say that the requested
item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a high
frequency chest wall oscillation device have not been met.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to
pre-approve a high frequency chest wall oscillation device (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission
criteria. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There
are no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the Plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LTACH services.