Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary for 
your condition. The Plan denied your request. The Plan says these items are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 necessary in this case. Our physician reviewer found that the Plan requires a
trial of drugs Orthovisc and Monovisc before they will approve the requested drug Hyalgan. Based on the
medical records provided, the enrollee has tried and failed Orthovisc but has not tried and failed
Monovisc. There is no indication that Monovisc 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 treatment with Hyalgan (J7321)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery consultations to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the surgery consultations. You say that the surgery consultations are medically necessary. The Plan denied your request. The Plan says the provider is out-of-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 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-approve the surgery consultations to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says a group 3 power wheelchair would not be appropriate for a beneficiary who has
diabetes with peripheral neuropathy.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the criteria is
not met for a group 3 power wheelchair, as there is no evidence of a neurological condition, myopathy, or
congenital skeletal deformity which is required for a Group 3 power wheelchair. The requested wheelchair
would exceed your medical needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX.
You asked the Plan to pre-approve Supartz FX. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Supartz FX is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Supartz FX.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Supartz FX. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Supartz FX. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not show that these drugs 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 Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tendon sheath injection provided on 
February 4, 2021. 
 
You asked the Plan to waive the copayment for a tendon sheath injection. You say that you received the 
injection in your doctor's office and were not informed that you would owe a facility fee. The Plan denied your 
request. The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.

The record shows that you received a tendon sheath injection at an outpatient hospital facility on February 4, 
2021. A tendon sheath injection is considered an outpatient surgical procedure. Therefore, you are responsible 
to pay the allowed amount of $242.11, which is less than the $295 copayment.   
 
You have been asked to pay $242.11 for a tendon sheath injection. A tendon sheath injection falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 a tendon sheath injection 
provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the specialist services provided on March 12, 2021.
You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan says the claim was 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. A $25 copay was applied. The services fall within the physician services benefit category. You also received a Methylprednisolone injection. You were charged a 20% coinsurance for this injection. The service falls within the Medicare Part B prescription drugs 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 cost shares for the specialist services provided on March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on August 2, 2021 with respiratory failure after cardio-pulmonary arrest. There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the jaw reconstruction (21249), alveoloplasty (41874) and dental surgery (41899) provided on November 9, 2020.

You asked the Plan to pay for the jaw reconstruction (21249), alveoloplasty (41874) and dental surgery (41899). You say that you suffer from a rare medical condition that required dental services. You say that this is not a cosmetic procedure and you cannot afford to pay. The Plan denied your request. The Plan says the services are not covered 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. Dental services must also be received from a network provider in order to be covered by the Plan. Therefore, we decided that the Plan does not have to pay for the jaw reconstruction (21249), alveoloplasty (41874) and dental surgery (41899) provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal orthosis (L0648) provided January 25, 2021.
You asked the Plan to pre-approve the spinal orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the records do not support the medical necessity of the purchased equipment.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the spinal orthosis. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found that 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. 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 no physical examination of the back by the ordering physician. 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 spinal orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal orthosis (L0648) provided January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on April 9, 2021.
You asked the Plan to pay for the services provided. You say that the provider can bill for services under the direction of the anesthesiologist. The Plan denied your request. The Plan says Original Medicare does not allow all professionals to directly submit charges.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim was submitted with a taxonomy identifying a non-eligible provider for a service typically billed under the facility claim. 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 anesthesia services provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and bitewing radiographic images (D0274) provided on November 4, 2019.

You asked the Plan to pay for a comprehensive oral evaluation, and bitewing radiographic images. You say that you want the Plan to reconsider payment. The Plan denied your request. The Plan says the time limit for filing has expired.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for a comprehensive oral evaluation, and bitewing radiographic images was not filed until January 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and bitewing radiographic images (D0274) provided on November 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic colonoscopy provided on July 15, 2020.

You asked the Plan to waive the copay for the colonoscopy. You say that there were two additional claims from the same provider with no liability. The Plan denied your request. The Plan says the claim was 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 $150 copay in an ambulatory surgical center for outpatient surgery. 

You have been asked to pay a $150 copay for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 copay for the diagnostic colonoscopy provided on July 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept in rural area (A0432) provided February 10, 2021.
You asked the Plan to pay for the paramedic intercept in rural area. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the coverage criteria were not met for this service.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept in rural area (A0432) provided February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130) to be provided in an
acute inpatient hospital setting.
You asked the Plan to pre-approve the requested procedure in an acute inpatient hospital setting. You say that
these services are medically necessary. The Plan denied your request. The Plan says they have agreed to cover
the total hip arthroplasty (27130) but only as an outpatient procedure. The Plan states that it is not necessary for
this procedure to be performed in an inpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient services are met in this
case. Our physician reviewer found that the enrollee is undergoing a planned elective total hip arthroplasty. The
enrollee is medically stable and has been provided medical clearance to undergo this procedure. The planned
procedure is listed under code 27130, which is not listed on the Centers for Medicare and Medicaid Services
inpatient only list. This procedure is currently approved as an ambulatory procedure. There is no
documentation provided to support the expectation that this enrollee may require greater than a two midnight
stay during and following the procedure. In this case, it is not medically necessary for the requested procedure
to be performed in an inpatient setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve a total hip arthroplasty (27130) to be provided in an acute inpatient hospital
setting.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing or skilled therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Specifically, your care needs can be 
provided at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the skilled 
nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT). 
 
You asked the Plan to pre-approve additional PT. You say that additional PT is medically necessary. The Plan 
denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT. 

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is 
not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved 
by the health Plan. The enrollee has had prior therapy of 16 outpatient visits approved and the records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services 
are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified 
therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional PT.