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

We decided that the Plan does not have to pay forthe daratumumab injection rendered to the enrollee on May 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code J9145 is not payable.The Plan must follow Medicare rules. Medicare rules say that OPPS status indicators identify if the code is payable under OPPS.We looked at the file and Medicare rules. The provider submitted a claim for procedure code J9145 under the OPPS. This code has an OPPS status indicator of K and was not billed with a required OPPS procedure code.Therefore, we decided that the Plan does not have to pay forthe daratumumab injection rendered to the enrollee on May9, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism and a medical alert bracelet.You asked the Plan to pre-approvea seat lift mechanismand a medical alert bracelet. You say that you have severe arthritis and need a seat lift mechanism.The Plan denied your request. The Plan says the documentation provided did not support a seat lift mechanism.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. There is no medical documentation of severe arthritis of the hip or knee or having a severe neuromuscular disease.A medical alert bracelet does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism and a medical alert bracelet have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism and a medical alert bracelet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says the standard care is available within the Plan's network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean office visit. You say that you would like this approval to see this physician. You say that this is the closest physician.The Plan denied your request. The Plan says there are multiple in-network providers available within 5 miles of the member's residence who can provide these services.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-approvean office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea health club membership for the enrollee.You asked the Planto pre-approvethe membership. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no supplemental benefit available which a fitness program or health club membership.The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits.Therefore, we decided that the Plandoes not haveto pre-approvea health club membership for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have numbness in your feet.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage oforthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea core buildup for teeth #2, 3, 7, 11, 12, 13, 18, 31.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 (D2950) are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvea core buildup for teeth #2, 3, 7, 11, 12, 13, 18, 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Planto pre-approve foot orthotics. You say that you would like reconsideration because you experience foot pain which limits where you can go. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto waive the copayment fora nuclear stress test received on November 4, 2019.You asked the Planto waive the copayment forthe test. You say that this should be paid for.The Plandenied your request. The Plansaysyou are only responsible for the $275 copayment.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 thatyou must pay a $275 copayment for advanced imaging services. You have been asked to pay a $275 copayment for the test. the test falls within the advanced imaging services 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 Plandoes not haveto waive the copayment fora nuclear stress test received on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visits provided by an out of network (OON) provider.You asked the Plan to pay foroffice visits. You say that you would like approval for these services.The Plan denied your request. The Plan says there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foroffice visits provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 27125) provided on September 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code cannot be verified.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 27125 is "Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)."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 services. Our reviewer says that the use of CPT code 27125 is not supported by the records provided. Our physician reviewer found that the enrollee underwent a hemiarthroplasty for treatment of a fracture, not a hemiarthroplasty for treatment of degenerative changes. Therefore, the billing of CPT 27125 is not supported.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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 27125) provided on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that you would like to see this physician because you have terrible anxiety driving on the highway.The Plan denied your request. The Plan says there are in-network providers available for these services.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. ThePlan 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-approvea specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mandibular partial denture (D5214).You asked the Plan to pre-approvethe mandibular partial denture. You say that the enrollee's teeth have significant breakdown due to decay and cracks, which are causing the enrollee to have sensitivity and discomfort.The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you have exceeded the benefit allowance for this service.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.Thoughthe Plan offers a dental benefit in excess of Medicare coverage, mandibular dentures, one of D5120, D5140, D5212, or D5214, are limited to once per 60 months. The record shows that you received a mandibular partial denture (D5212) on September 28, 2015 and your mandibular dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepre-fabricated post and core in addition to crown (D2954) on teeth #6 and 8.You asked the Plan to pre-approvepre-fabricated post and core in addition to crown. You say that you feel that these dental services are necessary.The Plan denied your request. The Plan says this item 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. Procedures not listed  in the benefits chart are not covered by the plan.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-approvepre-fabricated post and core in addition to crown (D2954) on teeth #6 and 8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean Apple Watch.You asked the Planto pre-approvethe Apple Watch. You say that you have a heart condition for which you have a defibrillator. The Apple Watch allows you to look at your heart rate and other important vitals. You believe that since it is a valuable monitor for you, that it should be covered.The Plandenied your request. The Plansaysthis item is not medical equipment and cannot be covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvean Apple Watch.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora platelet rich plasma injection (0232T) provided on October 16, 2019.You asked the Plan to pay fora platelet rich plasma injection. You say that you were told this would be covered.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that the services represented by CPT code 0232T are not reasonable and necessary.We looked at the file and Medicare rules. The service at issue is not reasonable and necessary under Medicare rules. Based on this information, we decided that Medicare rules for coverage of a platelet rich plasma injection have not been met.Therefore, we decided that the Plan does not have to pay fora platelet rich plasma injection (0232T) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvechiropractic services. You say that you cannot afford to pay for these services out-of-pocket, and you have no reason to believe that physical therapy will be effective for your issue.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network chiropractor if you meet criteria.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve7 additional occupational therapy visits for the enrollee.You asked the Plan to pre-approveadditional services. The Plan denied your request. The Plan says there is no need for continued skilled needs of a therapist.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The file shows that 10 occupational therapy visits were requested for the enrollee. The Plan has agreed to approve 3 visits. 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 additional services. Our physician reviewer found that the records indicate this enrollee has atherosclerotic heart disease and chronic pain. Balance is poor and repeated falls are noted. The right hand lacks strength and coordination. Therapy has been utilized and recent records indicate activities of daily living still require anywhere from minimal to moderate assist. Treatments have included education regarding a home exercise program. For debility and repeated falls, physical therapy and occupational therapy is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication that prior PT/OT has served to provide sustained, significant improvement in pain and/or function and there areno indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 additions services have not been met.Therefore, we decided that the Plan does not have to pre-approve7additional occupationaltherapy visits for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora basic metabolic panel (80074), blood count (85014) and ultrasound guidance (76937) provided on September 26, 2019.You asked the Plan to pay forthe metabolic panel, blood count and ultrasound guidance. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records submitted do not support the services that were billed.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 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 metabolic panel, blood count and ultrasound guidance. Our reviewer says that CPT codes 80047, 85014 and 76937 donot meet criteria for billing or reimbursement consideration. Our reviewer found no laboratory reports have been submitted for review and the provided US was not performed as part of a vascular access procedure. We looked at this coder's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the metabolic panel, blood count and ultrasound guidance have not been met.Therefore, we decided that the Plan does not have to pay fora basic metabolic panel (80074), blood count (85014) and ultrasound guidance (76937) provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation.You asked the Planto pre-approve the cardiac rehabilitation. You say that you would like reconsideration because you are not able to exercise without shortness of breath. The Plan denied your request. The Plan says there is not enough documentation to determine the medicalnecessity of this service.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 the cardiac rehabilitation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no documented covered indications for the procedure and it is not being furnished in a setting appropriate to your medical needs and condition.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 cardiac rehabilitation have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvearthroscopic shoulder surgeryYou asked the Plan to pre-approvethe arthroscopic shoulder surgery. You say that the surgery is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says that the information does not support that this care is needed to treat the member'scondition and does not meet the coverage criteria for shoulder surgery.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the arthroscopic shoulder surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a 6-month history of worsening left anterior shoulder pain and snapping. Functional limitations are noted in activities of daily living. Clinical exam findings are consistent with imaging evidence of a biceps pulley injury with significant rotator cuff tendinopathy and partial thickness tearing. He has failed to improve with 6 months of activity modification, positioning, and medications.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 arthroscopic shoulder surgery have been met.Therefore, we decided that the Plan has to pre-approvearthroscopic shoulder surgeryIf the Plan doesnot 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.