Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 1-hour home health nurse visits, once weekly (G0299/G0300), and home health aide services (G0156), 13 hours per week.
You asked the Plan to pre-approve the home health services. You say that the requested services are necessary. The Plan denied your request. The Plan says the enrollee is not demonstrating any skilled nursing needs and has significant help and assistance through personal care services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. The reviewer found that you do not have documented skilled therapy needs. Therefore, the reviewer found that the requested home health services are not medically reasonable or 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 the home health services have not been met. Specifically, the records do not show that you do not have a need for skilled services. Therefore, we decided that the Plan does not have to pre-approve 9 1-hour home health nurse visits, once weekly (G0299/G0300), and home health aide services (G0156), 13 hours per week.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that Entyvio is more gut-specific The Plan denied your
request. The Plan says the enrollee has not tried and failed Humira.
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 Entyvio. Our physician reviewer found
that the enrollee has a history of Crohn's disease. The Plan requires a trial of Humira before they will approve
the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no
documentation provided indicating that the Plan's required drug likely be less effective and/or likely have
adverse effects for this 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 Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection rendered on December 9,
2020.

You asked the Plan to waive the coinsurance for these services. You say that the hospital states you had an
injection, but you didn't. The Plan denied your request. The Plan says the coinsurance was 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%
coinsurance for each Medicare-covered Part B drug.

Review of the file shows that you received a Part B drug injection on December 9, 2020. The records show that
you received a Prolia injection. You have been asked to pay a 20% coinsurance for these services. These
services fall within the Medicare-covered Part B drug 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
coinsurance for the injection rendered on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
You asked the Plan to pre-approve the deep sedation/general anesthesia services. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services 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.
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 the first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a cervical plexus block (64999) provided on September 14, 2020.
You asked the Plan to pay for a cervical plexus block. You say that this code is supported. The Plan denied your request. The Plan says that this cannot be paid 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. 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 a cervical plexus block. Our reviewers says that the use of this code is supported by the records. Our physician reviewer found Current Procedural Terminology (CPT) codes 64402, 64410, and 64413 have been deleted, and instead, code 64999 will be used to report the injection of anesthetic agents or steroids to the facial nerve, phrenic nerve, or cervical plexus. 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 cervical plexus block have been met. Therefore, we decided that the Plan has to pay for a cervical plexus block (64999) provided on September 14, 2020.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio at 300 mg every four weeks.
You asked the Plan to pre-approve Entyvio at 300 mg every four weeks. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Entyvio at 300 mg every four weeks.
Our reviewer says that the documentation does support that the requested drug and dosage are medically
reasonable and necessary. Our physician reviewer found the enrollee has experienced loss of Entyvio
therapeutic drug response as evidenced by colonoscopically active disease in association with subtherapeutic
serum drug level. Dose-optimizing Entyvio at this juncture as requested to every 4 weeks is not only common
practice in Gastroenterology, but is generally safe, effective, and medically appropriate for the enrollee.
Therefore, the enrollee meets criteria for the requested drug at the requested dosage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio at 300 mg every four weeks have been met. Therefore, we decided that
the Plan has to pre-approve Entyvio at 300 mg every four weeks.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on November 12, 2020.
You asked the Plan to waive the coinsurance for the back brace. You say that you do not think you should have to pay this bill because you were ready to send the brace back. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for all other in-network Medicare-covered prosthetic devices and supplies. You have been asked to pay $259.57 which is 20% of the allowed amount for the back brace. The allowed amount is $1,297.87. ($1,297.87 x 20% = $259.57). The back brace falls within the "Prosthetic devices and related supplies" 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 coinsurance for the back brace provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from February 6, 2021, through February 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $350 per day for days 1-5 and $0 after day 5, each time you are admitted to an acute care hospital.
You have been asked to pay $1050 ($350 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from February 6, 2021, through February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating provider on December 10, 2020.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you were never told that you would have this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for outpatient surgery.

You have been asked to pay a $100 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery 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 copayment for cataract surgery provided by a participating provider on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, extraspinal chiropractic manipulations, acupuncture, therapeutic services, and use of a transcutaneous electrical nerve stimulation (TENS) unit provided by a chiropractor from January 20, 2021, to January 29, 2021.
You asked the Plan to pay for chiropractic services. You say that you were not informed that these procedures would not be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit, extraspinal chiropractic manipulations, acupuncture, therapeutic services, and use of a transcutaneous electrical nerve stimulation (TENS) unit provided by a chiropractor from January 20, 2021, to January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amphetamine/dextroamphetamine tablets.

You asked the Plan to pre-approve amphetamine/dextroamphetamine tablets. You say that you would like the
Plan to reconsider their denial. The Plan denied your request. The Plan says amphetamine/dextroamphetamine
tablets are not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve
amphetamine/dextroamphetamine tablets.

Benefits for amphetamine/dextroamphetamine tablets may be available under Medicare Part D. Contact the
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided by a chiropractor from January 4, 2021 to January 18, 2021.

You asked the Plan to pay for the services provided by a chiropractor. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for the services provided by a chiropractor from January 4, 2021 to January 18, 2021 due to the medical records submitted appearing to be altered without a valid signature. However, the records provided do not demonstrate that they have been altered in any way. We find that the Plan has not substantiated their reasoning for denial of payment. Therefore, we decided that the Plan has to pay for the services provided by a chiropractor from January 4, 2021 to January 18, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Durolane injection into the right knee.
You asked the Plan to pre-approve Durolane, Hyaluronan or derivative, Durolane, for intra-articular injection,
1 mg (J7318). You say that you want the enrollee to be treated with this drug. The Plan denied your request.
The Plan says the enrollee has not first tried and failed Orthovisc and Monovisc.
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 Durolane, Hyaluronan or derivative,
Durolane, for intra-articular injection, 1 mg (J7318). Our reviewer says that the drug is not medically
reasonable and necessary. Our physician reviewer found the enrollee has not trialed one viscosupplemental
treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that one of these be
trialed first. The documentation does not outline contraindications or reasons these medications were not
considered. Without the support of the documentation, Durolane is not approved as step criteria have not been
met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane, Hyaluronan or derivative, Durolane, for intra-articular injection, 1
mg (J7318) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Durolane
injection into the right knee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 10, 2020. You asked the Plan to waive the copayment for the MRI. You say that you do not recall having a copayment for MRIs. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $285 copayment for each in-network Medicare-covered advanced imaging service.

You have been asked to pay a $285 copayment for the MRI. The MRI falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 MRI provided on October 10, 2020. 

Please note, our decision is only regarding the October 10, 2020 date of service. Please contact the Plan directly for any questions regard previous years' billing.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Yupelri 175 mcg/3 mL solution (J7677).
You asked the Plan to pre-approve Yupelri 175 mcg/3 mL solution. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the accepted use of this drug requires the use of no more than 5250 mcg per month.
The Plan must follow Medicare rules. Medicare rules say that the maximum dosage per month of Yupelri that is reasonable and necessary is 5250 mcg per month. We looked at the file and Medicare rules. In this case, the medical records indicate that the enrollee will take 175 mcg of Yupelri per day. 175 mcg multiplied by 30 days indicates that the enrollee will take 5250 mcg per months which is not greater than the maximum dosage level as allowed per the LCD. Based on this information, we decided that Medicare rules for coverage of Yupelri 175 mcg/3 mL solution have been met. Therefore, we decided that the Plan has to pre-approve Yupelri 175 mcg/3 mL solution (J7677).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 22, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on October 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy office visit provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy office visit. You say that you were unaware the authorization was no longer active. The Plan denied your request. The Plan says no prior authorization was obtained.
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 psychotherapy office visit provided on January 20, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient programmer (external) for use with an implantable programmable neurostimulator pulse generator, replacement only (L8681) provided on August 28, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as you have not provided an order from the treating physician.
The Plan must follow Medicare rules. Medicare rules say that all DMEPOS items require a written order/prescription from the treating practitioner for Medicare payment as a condition of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the documentation provided did not include an order from the treating physician that was issued before this item was supplied to the member. Medicare rules say that all DMEPOS items require a written order/prescription from the treating practitioner for Medicare payment as a condition of payment. Therefore, we decided that the Plan does not have to pay for the patient programmer (external) for use with an implantable programmable neurostimulator pulse generator, replacement only (L8681) provided on August 28, 2020.