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

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. 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 Ilumya. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the enrollee is a 71 year old female with plaque psoriasis. The Plan requires a trial of Remicade or Inflectra and Stelara 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant surgery (code D6010), bone graft (code D6104), and custom abutment (code D6057).
You asked the Plan to pre-approve dental services. You say that the provider said these services were medically necessary, and you are in constant discomfort. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not covered by the Plan's dental benefits.
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 a dental implant surgery (code D6010), bone graft (code D6104), and custom abutment (code D6057).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy with argon plasma coagulation done at an inpatient level of care, provided on April 2, 2021.

You asked the Plan to pay for the colonoscopy done at an inpatient level of care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation provided did not support the need of inpatient services however ambulatory surgery level of care is approved.

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 the colonoscopy done at an inpatient level of care. Our reviewer says that the inpatient service was not considered medically reasonable and necessary in this case. Our physician reviewer found prior to and during the procedure, the patient did not have any unstable disease process or high risk of complication or expected prolonged recovery to justify inpatient services. Based on the provided documentation, the patient was not expected to require hospital services that would likely cross 2 midnights. The colonoscopy was not medically necessary to be performed at an inpatient level of care. 

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 colonoscopy done at an inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy with argon plasma coagulation done at an inpatient level of care, provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a COVID-19 test (U0003) provided on November 20, 2020.

You asked the Plan to pay for a COVID-19 test. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this must be billed by the SNF.

The Plan must follow Medicare rules. Medicare rules say that "Part A" consolidated billing requires that a SNF must include on its Part A bill almost all of the services that a resident receives during the course of a Medicare-covered stay. 

We looked at the file and Medicare rules. The record shows that the enrollee was in a covered SNF stay when the service at issue was received. This service is subject to consolidated billing and must be billed by the SNF. Based on this information, we decided that Medicare rules for coverage of a COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for a COVID-19 test (U0003) provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on March 5, 2021.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician as required per CMS guidelines. Also, the documentation submitted did not sufficiently document the member's medical condition to support the medical necessity for the billed supply code.

The Plan follows Medicare rules. Medicare rules say that knee orthotics are covered when certain criteria are met.

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 knee orthosis and suspension sleeve. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for one-unit of scaling in presence of generalized moderate or severe gingival inflammation. We decided that the Plan does not have to pay for one unit of scaling in presence of generalized moderate or severe gingival inflammation.
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation. You say that you would like the Plan to pay for the services. The Plan says that you have had the diagnosis of periodontitis and have previously had periodontal root planing and scaling performed on February 23, 2017, and May 4, 2017. Therefore, the services at issue are not appropriate as you have periodontal disease and are not covered.
We decided that the Plan has to pay for one unit of scaling in presence of generalized moderate or severe gingival inflammation.
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. This benefit includes one unit of scaling in presence of generalized moderate or severe gingival inflammation, per calendar year. The Plan hasn't provided medical records to show prior tooth history. Without medical records, the denial cannot be substantiated. You are covered for one unit of this service per year, per the EOC. Therefore, we decided that the Plan has to pay for one unit of scaling in presence of generalized moderate or severe gingival inflammation.
We also decided that the Plan does not have to pay for one unit of scaling in presence of generalized moderate or severe gingival inflammation.
Specifically, you are only covered for one unit of the service at issue, per calendar year. Therefore, we decided that the Plan does not have to pay for one unit of scaling in presence of generalized moderate or severe gingival inflammation.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on August 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 asked our coding 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 code 97110 is not supported by the records provided. Our coding reviewer found that the medical records
document that the service was performed in a home health or hospice setting. Code 97110 is not the most appropriate code to represent the service performed. There is a more appropriated Healthcare Common Procedure Coding System code to use to bill this service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97110) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was no obtained for these 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 laboratory services provided on March 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the physician services provided from January 15, 2021, to March 1, 2021.
You asked the Plan to waive the copays for the services provided. You say that you are being charged more for your copays. The Plan denied your request. The Plan says the claims were processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
The file shows that you received a specialist office visit on January 15, 2021. You were charged a $10 copay. The service falls within the physician services benefit category.
You received a myocardial imaging test on January 25, 2021. You were charged a $20 copay. You also received a cardiovascular stress test. You were charged a $10 copay. The services fall within the outpatient diagnostic tests benefit category.
You received a duplex scan of extracranial arteries on January 28, 2021. You were charged a $20 copay. The service falls within the outpatient diagnostic tests benefit category.
You received an ultrasound on February 12, 2021. You were charged a $20 copay. The service falls within the outpatient diagnostic tests benefit category.
You received a specialist office visit on March 1, 2021. You were charged a $10 copay. The service falls within the physician services benefit category.
You have been asked to pay the correct amounts 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 copays for the physician services provided from January 15, 2021, to March 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 100 trips.
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says you have exceeded the benefit allowance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 100 trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on March 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the behavioral health services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 behavioral health services provided on March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on October 11, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says a panel constitutes a single procedural service.

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 looked at the file and the rules. Since a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on October 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and a suspension sleeve (L2397), provided on March 20, 2021, through March 31, 2021.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no proof of delivery for these items.

The Plan follows Medicare rules. Medicare rules say that knee orthotics are covered when certain criteria are met. 

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 knee orthosis and suspension sleeve. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and a suspension sleeve (L2397), provided on March 20, 2021, through March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on August 21, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee informed you that they were covered under Original Medicare. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on August 21, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the anticoagulant management of patient taking warfarin (93793) provided January 6, 2021, to March 8, 2021.

You asked the Plan to waive the copayment for the anticoagulant management. You say that you would like these claims reprocessed. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 $5 copayment for lab services.

You have been asked to pay a $5 copayment for the anticoagulant management services. These services falls within the lab 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 Plan does not have to waive the copayment for the anticoagulant management of patient taking warfarin (93793) provided January 6, 2021, to March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic tests provided on January 5, 2021
You asked the Plan to waive the copays for the testing services. You say that you received services during an office visit. The Plan denied your request. The Plan says the claims processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copay for x-rays, and an $11 copay for all other diagnostic procedures and tests. The file shows that you received an x-ray of the knee billed by your provider. You were charged $30.50 for the x-ray services. Because the amount is less than the $35 copay, you were charged the lesser amount. You also received a duplex scan billed by a hospital facility. You were charged an $11 copay.
The services fall within the outpatient diagnostic tests 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 copays for the diagnostic tests provided on January 5, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you need continued care. The Plan denied your request. The Plan says your needs are custodial.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you no longer have skilled nursing or therapy needs. You are receiving oral medication and your vital signs are stable. After the therapy you have received, you are a at contact guard assist level with functional mobility. You do not meet severity of illness or intensity of service criteria for skilled nursing facility care. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.