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

We decided that the Plan does not have to pre-approve Supartz FX (J7321) knee injections.
You asked the Plan to pre-approve Supartz FX Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular injection, per dose (J7321). You say that you would like to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee hasn't first tried and failed Monovisc and Orthovisc.
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 Supartz Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular injection, per dose (J7321). Our reviewer says that the drug is not medically necessary. Our physician reviewer found the documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Supartz is not approved as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz Hyaluronan or derivative, Hyalgan, Supartz or visco-3, for intra-articular injection, per dose (J7321) have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX (J7321) knee injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve power scooter. You say that you cannot walk long distances and your legs cannot support you. The Plan denied your request. The Plan says you do not meet the Medicare criteria for this power scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that you do not meet the Medicare criteria for the requested power scooter. Our physician reviewer found the documentation does not indicate that you are unable to accomplish mobility-related activities of daily living in your home. There is also no indication that you are unable to use a manual wheelchair or even a cane/walker
for assistance with mobility. This motorized scooter is 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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transport (A0429) provided on November 30, 2020.

You asked the Plan to pay for the emergency ambulance transport. You say that the claim was filed with the QL modifier because it identifies that an enrollee was pronounced dead after the ambulance was dispatched. You also say that this is an approved procedure and modifier combination and should be processed for payment. The Plan denied your request. The Plan says the claim was billed with a CPT code and modifier that is not reimbursable.

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 code A0429 is not supported in the record. Specifically, it is not appropriate to bill CPT code A0429 with modifier QL. There is a more appropriate CPT code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transport (A0429) provided on November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is still dealing with pain. The Plan denied your request. The Plan says that the enrollee has stabilized medically and no longer requires daily skilled therapies; and has no need of daily skilled nursing care. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on October 15, 2021.
You asked the Plan to pay for inpatient hospital services. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says inpatient care was 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 pay for inpatient hospital services. Our reviewer says that the inpatient level of care services was not medically necessary or reasonable. Our physician reviewer found the review indicates that the enrollee did not require or receive any inpatient level of care services on October 15, 2020. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Specifically, the continued inpatient level of care was not medically necessary. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that the enrollee has undergone a dramatic weight loss. You say that the enrollee's current dentures have become too large for their mouth. You say that the enrollee is not able to eat as a result. You also say that the dentures are necessary. The Plan denied your request. The Plan says complete dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.

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 and complete dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture that you received on March 22, 2018, and a complete lower denture that you received on January 23, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (K0801).
You asked the Plan to pre-approve the heavy-duty power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty power wheelchair is covered for a beneficiary weighing 285 to 450 pounds. We looked at the file and Medicare rules. The record shows the enrollee's last weight was 198 pounds. A heavy-duty power wheelchair is only covered for beneficiaries over 285 pounds. Based on this information, we decided that Medicare rules for coverage of the heavy-duty power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (K0801).
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 February 1, 2021.

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; therefore, the billed code cannot be verified. 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 February 1, 2021.
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 an Intracept procedure. You say that the requested procedure fills a treatment gap for patients that do not receive adequate relief from traditional conservative methods and don't have instability to indicate that fusion is the appropriate treatment. You say that the Intracept procedure received FDA clearance, is safe, is efficacious and is effective. The Plan denied your request. The Plan says the Intracept procedure is considered experimental and investigational.
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 an Intracept procedure. Our reviewer says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is being treated for low back pain, lumbar spondylosis, and intervertebral disc degeneration. She presented with low back pain that is moderate to severe with associated symptoms including aching, numbing, and tingling. She notes pain in her lower back, from the waist to just below her buttocks. The pain is worsened upon sitting (bearing weight), standing up from sitting, or moving the back. She has a history of rupturing L3 when she was 20 years old. Occasionally, her right leg will go numb.
However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. The requested Intracept procedure is noted to be a "potential" beneficial treatment. Food and Drug Administration (FDA) criteria would only have been plausibly met if the enrollee had chronic low back pain generators that had been clearly delineated as being linked to the spinal vertebral body(s) in origin. This was not the clinical data set in this enrollee's clinical milieu. FDA criteria were not met. The noted magnetic resonance imaging (MRI) studies (as well as provided exams) indicate plausible other factors contributing to the ongoing low back pain. The non-radiating midline back pain, pain-aggravating and pain-relieving factors and occasional right leg numbness were/are all non-specific to pathologic entities and/or the considered procedure. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept procedure at L3-L4 is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014) and an exam of the back part of the eye with optic nerve drawing (92202) provided on March 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam and an ophthalmoscopy. You say that a provider performing services in a nursing home facility is not responsible to obtain authorization. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a medical eye exam (92014) and an exam of the back part of the eye with optic nerve drawing (92202) provided on March 26, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prism press-on lenses (V2718) provided on December 30, 2020. You asked the Plan to pay for prism lenses. You say that you were given a new prism lens to correct your double vision issue. You also say that you contacted the Plan and they advised, you did not owe the bill. The Plan denied your request. The Plan says this is not a covered service according to your plan of benefits.
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 these services when The Plan contract says that you receive one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. We looked at the file and the Plan's rules. The services at issue are not covered benefits. The Plan contract confirms that you do not have any coverage for glasses or eyewear unless it is directly after cataract surgery. Based on this information, we decided that the Plan's rules for coverage of prism lenses have not been met. Therefore, we decided that the Plan does not have to pay for prism press-on lenses (V2718) provided on December 30, 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 this enrollee needs inpatient rehabilitation care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in another setting.
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 based on the review of available records, the enrollee does not meet Medicare criteria
for coverage of an IRF admission. Based on the enrollee's current medical stability and lack of medical
complexity, there is no need for physician supervision three times per week for the ongoing management of
any active acute exacerbations of chronic medical conditions. There is no evidence of an indication for an
intensive therapy program with therapy three hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. The requested IRF admission is not medically necessary based
on a lack of medical complexity and lack of identifiable rehab nursing 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. 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 pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is a superior treatment. The Plan denied your request. The Plan says this should only be performed in clinical trials.
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 proton beam radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling data to suggest that proton therapy is superior to or more beneficial than other treatments. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. While the enrollee has enrolled in a registry study, registry studies are not clinical trials or studies and have a much less rigorous development process.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a measurement of corneal pressure diagnostic test (92145) provided on March 9, 2021.
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you paid a copayment on the date of service and you would like to appeal the balance remaining. The Plan denied your request. The Plan says the copayment you are being charged 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 $50 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $13.69 copayment for an outpatient diagnostic test. The records show that you had an office visit with a specialist and a $45 copayment applied. The records also show that on this visit, you received an outpatient diagnostic test to measure your corneal pressure. The service at issue is a separate cost share from the specialist office visit cost share. The EOC confirms that $50 is the required copayment for this service. You have been asked to pay a copayment of $13.69, which is less than the Plan's contracted amount. 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 measurement of corneal pressure diagnostic test (92145) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99203) provided on February 22, 2021.
You asked the Plan to waive the copayment for an office visit. You say that your visit with the provider was for a routine exam. The Plan denied your request. The Plan says you received a medical eye exam and the copayment you are being charged 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 $35 copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered benefits.
You have been asked to pay a $35 copayment for an office visit. The records show you had a medical eye exam
with a specialist, for dry eyes. The EOC confirms $35 is the required copayment for this service. 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 office visit with a specialist (99203) provided on February 22,
2021.