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

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided November 7, 2019.You asked the Plan to pay forthe orthosis. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelinesThe Plan must follow Medicare rules.Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore,we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tissue conditioning (CPT D5850).You asked the Plan to pre-approve the tissue conditioning. You say that  The Plan denied your request. The Plan says the service which remains in dispute is 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 tissue conditioning (CPT D5850).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 5, 2020 by an out of network (OON) provider.You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe physician services provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V and Factor II gene analysis for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is limited evidence to support this diagnostic testing.
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 genetic tests are not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V and Factor II gene analysis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment forthe dental services provided on December 19, 2019.You asked the Plan to provide additional payment forthe dental services. You say that you have a $0 copay for preventive and diagnostic services.The Plan denied your request. The Plan saysthat your provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.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 covers the dental services from an out-of-network dental provider but you may pay more. We looked at the file and Medicare rules.The file indicates the Plan paid up to the contracted rate.Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to provide additional payment forthe dental services provided on December 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy provided on January 16, 2020.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say thatyou didn't expect a copayment since your doctor requested the procedure that is covered by Medicare. The Plan denied your request. The Plan says the copayment 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 $250 for each in-network, Medicare-covered ambulatory surgical center visit.You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a diagnostic colonoscopy was ordered and performed. 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 forthe diagnostic colonoscopy provided on January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided from December 4, 2019 to December 31, 2019.
You asked the Plan to pay for the skilled nursing facility services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided from December 4, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with codes A6533 and A6534.You asked the Plan to pre-approvethe compression stockings. You say that your primary care physician recommended that you wear the stockings due to swelling from arthritis.The Plan denied your request. The Plan says the items requested are non-covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 and A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with codes A6533 and A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from January 13, 2020 to January 16, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you do not feel you should be charged since it should be covered by your insurance. You say the hospital stay was medically necessary. 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 $150 copayment per visit. You have been asked to pay a $150 copayment for the observation stay. The observation stay falls within the "Outpatient Hospital Observation" benefit category. The record shows your observation stay was a covered service.
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 observation stay provided from January 13, 2020 to January 16, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires 3 hours of therapy a day, and daily physician visits.The Plan denied your request. The Plan says there is no ongoing treatment of acute or acute on chronic medical conditions.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 physician reviewer found that the enrollee was recently admitted following ventricular fibrillation and arrest. The enrollee is now stabilizing. She is functioning at minimal assist for activities of daily living with occupational therapy. Her hemodynamic parameters are stabilizing. The complexity of the enrollee's nursing, medical, and rehab needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
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.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to avoid infection to her surgical sites, and therapy to help maintain weight bearing status. The Plan denied your request. The Plan says the enrollee does not have complex nursing or medical needs requiring an intensive inpatient hospital setting.
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 physician reviewer found that the enrollee tripped and fell, suffering bilateral wrist comminuted intra-articular fractures. She is at moderate assist for mobility, and at maximum assist for activities of daily living. The complexity of the enrollee's nursing, medical, and rehab needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil Citrate.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says given the current information, this drug is not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Sildenafil Citrate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services provided on February 14, 2020.You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received non-covered chiropractic services (99202) on the date of service at issue in this appeal.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, CPT code 99202 is not manual manipulation of the spine. You are responsible for the $90 charge for CPT code 99202.The rules also say that Plan's must disclose to its members the benefits offered under the Plan including applicable cost sharing amounts.  The records show you received Medicare-covered chiropractic services, CPT code 98941. You have been asked to pay a $40.81 copayment for the Medicare-covered chiropractic services provided by an out-of-network provider, which is less than the contracted $65 copayment amount. 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 pay for the non-covered chiropractic services provided on February 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from October 9, 2019 through October 10, 2019.
You asked the Plan to pay for the post stabilization inpatient care. You say that this care was medically necessary. The Plan denied your request. The Plan says that the clinical information provided does not support the medical necessity of continued stay at acute inpatient level of care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval 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 the post stabilization inpatient care. Our reviewer says that the post stabilization inpatient care was not medically reasonable and necessary for the enrollee in this case. The enrollee was stable for discharge or could have been transferred to a Plan facility and no longer required inpatient level of care services. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any date of service. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for continued inpatient care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the post stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization inpatient care provided to the enrollee from October 9, 2019 through October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysneeds can be met with part-time skilled services in a long-term care facility.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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. Vital signs are stable. SNF is not 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interim complete denture, maxillary (D5810) and interim complete denture, mandibular (D5811) provided on December 27, 2019.
You asked the Plan to pre-approve the dental services. You say that due to a side effect of prescribed medications, your teeth were damaged and crumbling. You had to have your remaining teeth pulled and permanent implants put in. The Plan denied your request. The Plan says these items are not covered under the plan benefits and dental services must be provided by an in-network provider.
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. Services not listed as covered under the Description of Benefits are not covered by the plan. Page 44 of the health plan contract also says that enrollee's must receive their services from an in-network provider. 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 interim complete denture, maxillary (D5810) and interim complete denture, mandibular (D5811) provided on December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Panitumumab (Vectibix).
You asked the Plan to pre-approve Vectibix. You say that the other drug is not working at all. The Plan denied your request. The Plan says the drug is not supported after progression on Cetuximab.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Vectibix. Our physician reviewer found that the request is for Vectibix monotherapy to treat metastatic colon cancer that has progressed during treatment with Erbitux (Cetuximab.) You have previously been treated with multiple chemotherapy regimens that included 5FU, Irinotecan and Oxaliplatin. The tumor was negative for KRAS. The requested use of the drug is not indicated if there has been previous treatment with Cetuximab. The documentation does not support that the drug is safe and effective or medically reasonable and necessary 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 Vectibix have not been met. Therefore, we decided that the Plan does not have to pre-approve Panitumumab (Vectibix).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that the enrollee has received other medications and her health is not improving. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to 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 Gel-One. Our physician reviewer found that the enrollee has primary osteoarthritis of the right knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show the enrollee has tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea medical alert device.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthis device is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who arenot sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea medical alert device