Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse the cost sharing amount for the bone replacement graft (D7953)
provided on December 6, 2019.
You asked the Plan to reimburse the cost sharing amount for the dental service. You say that the Evidence of
Coverage says bone replacement grafts are listed as a covered service. You say that you should only be
responsible for the 20% coinsurance since the service was accompanied by a surgical procedure. The Plan
denied your request. The Plan says that bone grafts and guided tissue regeneration in conjunction with
extractions are not a covered service.
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. There were no medical records provided in the case file to substantiate the Plan's
claim that the bone replacement graft was provided in conjunction with an extraction. Without medical records,
there is no way of knowing the "surgical procedure" that was performed. Therefore, we decided that the Plan
has to reimburse the cost sharing amount for the bone replacement graft (D7953) provided on December 6,
2019.
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 because of multiple illnesses the enrollee needs incontinence supplies.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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 11, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you had a wellness visit and you should not be charged a $5 office visit copayment. The Plan denied your request. The Plan says you have been charged 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 $5 copayment per primary care physician (PCP) visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows the visit was a check-up for hyperlipidemia and constipation.
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 office visit provided on December 11, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc (J7324).
You asked the Plan to pre-approve the Orthovisc. You say that the member has experienced minimal relief with corticosteroid injections and hyaluroninc acid injections are the next logical treatment. The Plan denied your request. The Plan says that the use of this drug is not helpful in treating knee pain.
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 the Orthovisc. Our reviewer says that evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current evidence based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. Our physician reviewer found a trial of Orthovisc injections is reasonably indicated for treatment of this enrollee's knee pain given the failure of comprehensive conservative treatment, persistent pain and functional limitations, and desire to delay surgical treatment. 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 Orthovisc have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc (J7324).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on November 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that these services were provided at a living facility. You say that these services are provided in good faith. 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 has network providers available who can provide 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 chronic care management provided on November 30, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 27, 2019 by an out of network provider.
You asked the Plan to pay for the non-emergent ambulance service. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization for the non-emergent ambulance service.
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 service 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 ambulance services provided on October 27, 2019 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (CPT 76981) provided on July 30, 2019.
You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan says this is not a benefit for the diagnosis listed.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 76981 is part of an edit pair with procedure code 76700. Procedure code 76700 is a column one code, and procedure code 76981 is a column two code. Procedure code 76700 has also been billed n this claim, which means that procedure code 76981 is denied and not eligible for payment. Therefore, we decided that the Plan does not have to pay for the ultrasound (CPT 76981) provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX You asked the Plan to pre-approve Supartz FX. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.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 member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects. 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 Supartz FX
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foreye injection services (J0178) provided December 20, 2019.You asked the Plan to waive the copayment foreye injection services. You say that you believe this number is excessive. The physician's charges are extremely high compared to the same services that you have received and what has been charged over the past three years.The Plan denied your request. The Plan says the claim was correctlyThe rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. for Medicare Part B prescription drugs.You have been asked to pay $380.98 for the eye injection services. The eye injection services fall 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 copayment foreyeinjection services (J0178) provided December 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 19, 2019 to October 18, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 19, 2019 to October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and the topical application of
fluoride varnish (D1206) provided on November 6, 2019.
You asked the Plan to pay for the dental services. You say that the Summary of Benefits says one dental x-ray
is covered every year. You say that the x-ray was part of your routine annual dental exam and cleaning. You
also say it is unreasonable to expect that you know the procedure codes associates with various types of dental
x-rays. The Plan denied your request. The Plan says bitewing x-rays and the topical application of fluoride
varnish are not listed as covered services.
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 bitewing x-rays and topical
application of fluoride varnish are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the bitewing x-rays (D0274) and the topical application of fluoride varnish
(D1206) provided on November 6, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan.
You asked the Plan to pre-approve the PET/CT scan. You say that this is medically required imaging. The Plan
denied your request. The Plan says that the enrollee has already had the three nationally covered PET scans.
There is not sufficient documentation to support a fourth at this time.
Please note: It appears that the Plan has miscounted the number of PET scans provided. The rules allow for one
PET scan for initial treatment strategy, then another three being nationally covered. Based on the information
provided by the Plan, it appears that the current request is for a third PET scan for subsequent treatment
strategy.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically 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 the PET/CT scan. Our reviewer says
that the requested imaging is shown to be reasonable and necessary. Our physician reviewer found this patient
has an aggressive diffuse large B-cell lymphoma and is being evaluated for autologous stem cell transplant. In
preparation she is receiving high dose chemotherapy. A PET scan is planned to evaluate the effect of high dose
chemotherapy and determine if the patient is eligible for high dose chemotherapy. If a good response is noted
on PET scan, then she will proceed to stem cell transplant. A cat scan would be unlikely to provide this
information. A poor response would necessitate more aggressive treatment. The service is reasonable and
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 the PET/CT scan have been met. Therefore, we decided that the Plan has to preapprove
a PET/CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat right radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation provided by the physician indicates that the pain relief from the previous procedure did not last a minimum of six months.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the RFA lesions did not last the six months of 50% pain relief required by the LCD. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat right radiofrequency ablation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on September 4, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that the Plan should pay this claim . The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 5, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records stating
exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on October 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The current medical status does not require intensive physician or nursing supervision in an IRF. The documentation does not indicate that the enrollee requires this on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvetherapeutic facet joint injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no documentation of successful diagnostic medial branch blocks.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will becovered when it is medically 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 the injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain, with radicular symptoms. An epidural steroid injection relieved 80% of your pain. The request is for therapeutic (not diagnostic) facet blocks. However, the health plan denies these procedures indicating that diagnostic medial branch blocks must be performed first. The requested procedures are medically reasonable and 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 injections have been met.Therefore, we decided that the Planhas to pre-approvetherapeutic facet joint injections for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual physical rendered to you on December 17, 2019.You asked the Plan to pay forthese services. You say that the Plan denied your request. The Plan says you exceeded the benefit limit.The Plan must follow Medicare rules. Medicare rules say that an annual physical exam is covered per lifetime. The Plan covers one annual physical exam per calendar year.We looked at the file and Medicare rules. The file shows that you previously received an annual physical exam on April 16, 2019 for which the Plan approved and paid. The annual physical exam rendered on December 17, 2019 exceeds the limit of one per calendar year.Therefore, we decided that the Plan does not have to pay forthe annual physical rendered to you on December 17, 2019