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

We decided that the Plan does not have to pre-approve use of Dalvance.
You asked the Plan to pre-approve Dalvance. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for Dalvance is correct, because the Plan requires
a trial of other appropriate antibiotics such as vancomycin before it will approve Dalvance.
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 Dalvance. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Dalvance. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drug of vancomycin. The documentation does
not support that this drug would likely be less effective and/or 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 Dalvance have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Dalvance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on February 22, 2021.
You asked the Plan to pay for the psychotherapy visit. You say that the enrollee has out of network benefits.
The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently
attempt to enroll in Medicare but are not eligible to do so. A Licensed Social Worker is not eligible to enroll in
the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy visit have not been met. The record shows this provider is a Licensed Social
Worker (LSW). LSWs are not eligible to enroll in Medicare which means this provider is not payable.
Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on February 22,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coronary artery bypass (33519).

You asked the Plan to pre-approve coronary artery bypass. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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 coronary artery bypass. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that although the patient has some dyspnea on exertion, he has no anginal chest discomfort and he has a long history of cigarette smoking and hypertension. There is no report of a pulmonary disease evaluation provided. His left ventricular (LV) function is normal, and his nuclear stress test did not show ischemia. Because of the concern for possible balanced ischemia, he was referred for a coronary computed tomography angiogram which showed some coronary calcium but only non-obstructive coronary artery disease and did not show significant fixed atherosclerotic disease greater than 40-50%. He has not had a cardiac catheterization or coronary arteriogram to further assess his coronary anatomy or fractional flow reserve testing (either angiography or CT based) to assess any anatomically borderline lesions for clinical significance. In the absence of significant documented anatomic disease, ischemia on physiologic stress testing, or known LV dysfunction, there are no reported appropriate guideline indications for coronary artery bypass grafting based on the provided clinical information. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of coronary artery bypass have not been met. Therefore, we decided that the Plan does not have to pre-approve coronary artery bypass (33519).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia services (D9222, D9223).
You asked the Plan to pre-approve anesthesia services. You say that you are going to have multiple extractions
and would like anesthesia services to be covered for these procedures. The Plan denied your request. The Plan
says the requested services are 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 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
general anesthesia services (D9222, D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pay for pneumatic compression device and appliance. You say that the enrollee meets Medicare criteria as she presents with proximal swelling that requires a trunk garment to address and has failed conservative therapies. The Plan denied your request. The Plan says the records do not support the criteria for medical necessity.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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 pneumatic compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the record indicates that the enrollee has bilateral lower extremity edema. Truncal involvement is not documented. A trial of an E0650 or E0651 device is not documented. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical tooth extraction (D7210) to be provided by an oral surgeon.

You asked the Plan to pre-approve the surgical extraction. You say that this tooth extraction is medically necessary and cannot be performed by a dentist. Your dental provider referred you to an oral surgeon to have the surgical extraction completed. The Plan denied your request. The Plan says this service is not covered by Medicare, and the Plan only covers certain dental services when they are performed by a participating general dentist. Dental services provided by an oral surgeon are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers supplemental dental services that are performed by a participating general dentist.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services performed by an oral surgeon are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical tooth extraction (D7210) to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 7, 2020, To March 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim paid. The Plan denied your request. The Plan says this is not the primary care physician listed. The Plan says that 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 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 an office visit provided on December 7, 2020, To March 12, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain with radiculopathy. Imaging has not shown any significant spinal stenosis. The Superion spacer is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 8, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says this provider prescribed the orthoses without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 8, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from March 8, 2021, through March 16, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you only rode the exercise bike and did basic exercises you could have done at home. You say that you don't agree with the bill and you are being overcharged. The Plan denied your request. The Plan says the copayments applied 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 $20 copayment per visit for Medicare-covered physical therapy and speech-language pathology services. Services performed at a hospital outpatient facility are subject to the outpatient hospital copayment.
You have been asked to pay a $20 copayment for each physical therapy service. The total amount you owe is
$100. Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from March 8, 2021, through March 16,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided August 11, 2020.

You asked the Plan to pay for the orthosis. You say that you have provided services based on the prescription and the notes received from the doctor. The Plan denied your request. The Plan says this supplier conducts unsolicited outreach telephone calls to enrollee's. Documentation indicates services are not necessary for treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure are a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the record indicates that the enrollee has lumbar spinal stenosis with neurogenic
claudication. The record further indicates that imaging has demonstrated mild spinal stenosis at L3-L4 and
severe central stenosis at L4-L5, the levels requested for treatment. The record does not indicate that these are
the only levels requiring treatment. The coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for extremity braces (L2397, L1833) provided September 8,
2020.
You asked the Plan to pay for the extremity brace. You say that the items were medically necessary. The Plan
denied your request. The Plan says the items were provided as a result of an unsolicited telephone consult.
Coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the extremity brace
have not been met. Therefore, we decided that the Plan does not have to pay for extremity braces (L2397,
L1833) provided September 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer 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 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 physician services provided on January 5, 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 the removal of torus mandibularis (D7473) and the removal of residual tooth roots (cutting procedure) (D7250) received April 13, 2021.
You asked the Plan to pay for the dental services. You say that you have not exhausted your $1,500 benefit yet. The Plan denied your request. The Plan says you have exhausted your $1,500 annual supplemental dental benefit allowance.
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 benefit is limited by a $1,500 annual allowance. The Plan has submitted claims evidence showing that you the allowance exhausted on April 13, 2021. $148 of this allowance was used on a dental claim from February 4, 2021, leaving $1,352 remaining in your annual allowance. On April 13, 2021 you were billed for dental services totaling $2,693. The Plan applied the remaining $1,352 of your dental allowance towards this claim, leaving you with a responsibility of $1,351 for dental services D7473 and D7250. Therefore, we decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) and the removal of residual tooth roots (cutting procedure) (D7250) received April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift.
You asked the Plan to pay for a stair lift. You say that your wife injured both legs in a fall on your stairway. There is just the 2 of you in a split-level house. The stair lifts installed was a medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift.