Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. You say that this request is medically necessary. 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 Hyalgan. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found The Plan requires a trial of Durolane, Euflexxa, Gelsyn-3, Supartz 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric facility admission.

You asked the Plan to pre-approve inpatient psychiatric facility admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric facility admission.

Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she is not a danger to self or others. Based upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of 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 inpatient psychiatric facility admission have not been met. Specifically, medically necessary services are available at a lower level of care. This means that admission into an inpatient psychiatric facility is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric facility admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastric emptying imaging study (78264, A9541) and provided on December 30, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the gastric emptying imaging study. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON 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 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. 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 the gastric emptying imaging study (78264, A9541) and provided on December 30, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold the member harmless for the inpatient hospital services provided on October 21, 2020, through October 30, 2020.

You asked the Plan to hold the member harmless for the inpatient hospital services. You say that you would like reconsideration because the member should not be held responsible for this bill. The Plan denied your request. The Plan says that the documentation does not support the need for an acute inpatient level of care. The Plan also says that the member is not liable for this bill.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the inpatient hospital services by a contract provider. The file does not show that the plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this means the inpatient hospital services is considered approved by the plan. Additionally, the Plan has verified that the member is not liable for the bill at issue. Therefore, we decided that the Plan has to hold the member harmless for the inpatient hospital services provided on October 21, 2020, through October 30, 2020.

If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 11, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.

You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that you can barely walk and need a power scooter. The Plan denied your request. The Plan says there is no physician order.

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. 

The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair or you can safely operate the PMD being requested. There is no physician order or face-to-face documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 13 and 15 and a pontic (D6245) for tooth #14.

You asked the Plan to pre-approve the retainer crowns and pontic. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says the records do not show that a crown on the abutment tooth is medically necessary. The Plan also says that tooth #'s 13 and 15 do not appear to have significant breakdown.

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 retainer crowns and pontic when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the retainer crowns and pontic. Our reviewer says that the requested services cannot be recommended. Our physician reviewer found the records submitted do not indicate that tooth #13 does not have pathologic destruction from trauma or caries on three or more surfaces involved and at least one cusp. The records submitted do not indicate that tooth #15 does not have pathologic destruction from trauma or caries on four or more surfaces involved and at least two cusps. Our reviewer found that the teeth supporting the bridge do not require crowns. Our physician reviewer also found that the elements of the coverage rule are not satisfied. 

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 retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 13 and 15 and a pontic (D6245) for tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 5, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 neuromuscular stimulator rendered on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted documentation does not demonstrate pain innervating from the facet joints.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation to support this request. The request also exceeds utilization limits. There is no documentation of range of motion limitations or of facet loading maneuvers.

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 pre-approve paravertebral facet joint injections
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 4, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex.

You asked the Plan to pre-approve Vertiflex. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee has lumbar spinal stenosis with neurogenic claudication. A note signed April 12, 2021 states that X-rays demonstrate that bone density and lumbar spine are inadequate to proceed with the requested procedure. The medical records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the eyeglasses (V2025, V2300) provided on March 18, 2021.

You asked the Plan to pay the full amount for the eyeglasses. You say that these glasses are necessary for you and you cannot afford the bill as you are living on a fixed income. The Plan denied your request. The Plan says they have paid the $100 allowed for the eyeglasses, but you are responsible for the remaining cost.

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 will pay up to $100 for eyeglasses or contacts every two years. 

We looked at the file and the Plan's rules. The Plan has paid the full $100 allowed for the glasses based on the contract. Therefore, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2025, V2300) provided on March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 29, 2021.

You asked the Plan to pay for a PET scan. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. 

We looked at the file and Medicare rules. The billed diagnosis code, C50.911, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.

Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 26, 2021 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee is unable to obtain a precertification or authorization for himself. The Plan denied your request. The Plan says the service was rendered by a non-contracted provider which requires authorization and there is not one on file.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 26, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient laboratory services provided on February 23, 2021.

You asked the Plan to waive the deductible for outpatient laboratory services. You say that lab cost-shares should be excluded from the deductible. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for certain type of services including outpatient diagnostic tests and therapeutic services and supplies.

The service at issue is subject to the Plan deductible of $300. The record shows that at the time this claim was processed, $147.02 of the $300 deductible had been met. The allowed amount of the claim is $64.87, resulting in a deductible obligation of $64.87. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time outpatient laboratory services was received on February 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient laboratory services (86334, 84165, 84155, 83883, 82784) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six surgical placements of implant bodies: endosteal implants (D6010 x6), six surgical accesses to an implant body (D6011 x6), six abutment supported porcelain/ceramic crowns (D6058 x6), six bone grafts at time of implant placement (D6104 x6), and mandibular implant /abutment supported removable denture for edentulous arch (D6111).

You asked the Plan to pre-approve the endosteal implants, surgical accesses to an implant body, abutment supported crowns, bone grafts, and mandibular implant /abutment supported removable denture. You say that you were told that this plan covers implants. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 six surgical placements of implant bodies: endosteal implants (D6010 x6), six surgical accesses to an implant body (D6011 x6), six abutment supported porcelain/ceramic crowns (D6058 x6), six bone grafts at time of implant placement (D6104 x6), and mandibular implant /abutment supported removable denture for edentulous arch (D6111).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 30, 2020 to August 31, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes for which Medicare makes payment based on HIPPS codes. 

We looked at the file and Medicare rules. The file shows that a valid RAP was not submitted. 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 home health services rendered from August 30, 2020 to August 31, 2020.