Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Prolia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of postmenopausal osteoporosis with a prior wedge compression fracture of the second lumbar vertebra. The documentation shows that the enrollee has tried an oral bisphosphonate and zoledronic acid, however no records are provided documenting that the enrollee failed the required drugs. There is no indication that the plan's required drugs 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight panel rendered on August 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight panel rendered on August 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health visit you had
on May 13, 2021.
You asked the Plan to waive the copayment for the outpatient mental health visit. You say that this was only a
short visit and you have not paid a copayment in the past. The Plan denied your request. The Plan says you
were charged this copayment 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 $35
copayment for outpatient mental health visits.
You have been asked to pay a $35 copayment for the outpatient mental health visit. This copayment applies
regardless of how long the visit lasts and regardless of what you may have paid in the past. 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 outpatient mental health visit you had on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 12, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you had to have a stitch removed from a previous surgery and you feel that due to the doctor's error you should not be responsible for the charges. 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 $20 copayment for specialist services. You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 12, 2021.
We note your complaint that a stitch was missed during a previous removal. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, 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 rendered on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology consultation to be provided by an OON
provider.
You asked the Plan to pre-approve the neurology consultation. You say that you were under the impression the
provider was in-network. You say you are losing function due to the nerve compression. 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 neurology consultation to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub transfer bench.
You asked the Plan to pre-approve the bench. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a tub transfer bench.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233-57) provided on March 9, 2021.
You asked the Plan to pay for code 99233 with modifier 57. You say that the medical records support the use of modifier 57 for code 99233. The Plan denied your request. The Plan says the medical records do not support the use of modifier 57 for code 99233.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are
spent at the bedside and on the patient's hospital floor or unit. The definition of modifier -57 is an evaluation and management service that resulted in the initial decision to perform the surgery. We asked our coder 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 code 99233 with modifier 57. Our reviewer says that the medical records do not support the use of modifier 57 for code 99233. Our reviewer found the record indicates that the procedure performed was incision and drainage, indicated by CPT code 10180 that has a global period of 10 days and is considered a minor surgical procedure. The modifier -57 is not applicable to minor procedures that include the evaluation and management service in the global period. The elements of the coverage criteria are not satisfied. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99233 with modifier 57 have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233-57) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies (S1015, S8301) provided to the enrollee on June 24,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says these codes are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
S1015:
IV tubing extension set
S8301:
Infection control supplies, not otherwise specified
We find that these codes are not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 pay for supplies (S1015, S8301) provided to the enrollee on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Insertion of tissue expander (11960) provided on July 15, 2021.
You asked the Plan to pay for code 11960. You say that the medical records support the billing of code 11960 provided on July 15, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of code 11960 provided on July 15, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 11960 is Insertion of tissue expander(s) for other than breast, including subsequent expansion.
We asked our coder 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 code 11960. Our reviewer says that the medical records do not support the billing of code 11960 provided on July 15, 2021. Our reviewer found the record indicates that the enrollee underwent placement of an external tissue expander. CPT code 11960 requires the insertion of a device whereas this device is external to the body. The elements of the coverage criteria are not satisfied. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 11960 have not been met. Therefore, we decided that the Plan does not have to pay for the Insertion of tissue expander (11960) provided on July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on June 6, 2021.
You asked the Plan to pay for the non-emergent ambulance services. You say that the ambulance services were medically necessary as the enrollee required medical supervision and was a high fall risk. The Plan denied your request. The Plan says the criteria for non-emergent ambulance transportation were not met, and the services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the criteria for non-emergent ambulance transportation was not met on the date in question. Our physician reviewer found the enrollee has dementia and is a high fall risk. The enrollee received no treatment during transportation. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on June 6, 2021.The documentation does not support that other means of transport (such as a stretcher van or wheelchair van) were contraindicated for this enrollee on the date in question. Supervision could be provided via these other methods of transport. Documentation does not support that the ambulance transport on
June 6, 2021, was 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 the non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on June 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided
on June 13, 2021.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
for the CT scan is a column II code to column I code 70496. This claim has not been billed with an appropriate
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450
provided on June 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular study to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the vascular study. You say that you would like the service done at the out-of-network provider. 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 vascular study to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
joint.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that radiofrequency ablation used for sacroiliac joint pain
is considered not medically necessary/investigational.
We looked at the file and Medicare rules. The requested RFA of the SI joint is considered not medically
necessary and investigational and therefore not covered. Therefore, we decided that the Plan does not have to
pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for speech therapy services you had at an outpatient hospital facility from June 1, 2021, to June 18, 2021.
You asked the Plan to waive the copayments for the speech therapy services. You say that you were told there would be no deductible for this service. You said that you would not have had the services if you had known about the copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for speech therapy at an outpatient hospital facility.
You have been asked to pay a $40 copayment per visit for the speech therapy services. You had these services at an outpatient hospital facility. 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 copayments for speech therapy services you had at an outpatient hospital facility from June 1, 2021, to June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 9, 2021.
You asked the Plan to pay for the problem focused exam. You say that you used a network provider and feel the service should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 problem focused oral exam once every 12 months. We looked at the file and Medicare rules. The Plan provided documentation showing that a problem focused exam was previously covered on June 8, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and periodontal scaling and root planing to be provided by a periodontist.
You asked the Plan to pre-approve the comprehensive oral evaluation and scaling and planing. You say that the regular dentist and hygienist said they cannot to perform these services because it has to be a periodontist. The Plan denied your request. The Plan says dental services are only covered by the Plan when they are performed by a participating general dentist. The Plan also says that services performed by a periodontist 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation and periodontal scaling and root planing to be provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve dental services from an oral surgeon. You say that your teeth are hurting a lot and our general dentist recommended you see an oral surgeon. The Plan denied your request. The Plan says dental care from an oral surgeon is not covered under your dental 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. Supplemental dental care must be performed by a participating general dentist. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services performed by anyone other than a participating general dentist are excluded from coverage under this benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary based on a diagnosis of type 2 diabetes mellitus without complications. The Plan denied your request. The Plan says a standard home blood glucose monitor appears appropriate for current blood glucose testing needs.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found it is not clear why more frequent glucometer checks would not suffice to provide the blood glucose data needed for improved
control. The enrollee is not on multiple daily injections of insulin, and not adjusting the doses based on blood glucose levels day to day. Therefore, the criteria is not met for coverage. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee