Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 28, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit since it was a medical vision check (Bilateral, Glare sensitivity, Endothelial corneal dystrophy). Eye refractions are only covered by the Plan if performed by the Plan's participating provider and performed as a routine vision screening.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on April 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43235) provided on February 26, 2021.
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an esophagogastroduodenoscopy, which is considered a surgical procedure, in an outpatient hospital setting. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $250 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an esophagogastroduodenoscopy, a surgical procedure provided in an outpatient hospital setting on February 26, 2021. You have been asked to pay a $250 copayment for the esophagogastroduodenoscopy. The
esophagogastroduodenoscopy 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 the esophagogastroduodenoscopy (43235) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic cast and occlusion analysis provided on March 4, 2021.
You asked the Plan to pay for the diagnostic cast and occlusion analysis. You say that you switched plans because you were informed this type of claim would be covered. You say that you were informed any dental claim up to a total of $2,000 annually would be reimbursed and the claim should be reversed. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the diagnostic cast and occlusion analysis are not covered benefits. Please note, the remaining dental service is also denied as the billed code is invalid and coverage cannot be verified. Therefore, we decided that the Plan does not have to pay for the diagnostic cast and occlusion analysis provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of an intraocular lens prosthesis to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve extracapsular cataract removal with insertion of an intraocular lens prosthesis to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 extracapsular cataract removal with insertion of an intraocular lens prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 4, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay for the billed service because they did not complete the ultrasound. 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 $150 copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $150 copayment for the ultrasound.
You have been asked to pay a $60.56 copayment for the ultrasound. The ultrasound falls within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows that a targeted right breast ultrasound of the area of pain in both right and left breasts was 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 for the ultrasound provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor foot (K5973).
You asked the Plan to pre-approve the microprocessor foot. You say that the microprocessor foot should be covered. The Plan denied your request. The Plan says the microprocessor foot was not demonstrated as necessary.
The Plan follows Medicare rules. Medicare rules say that 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 microprocessor foot. Our reviewer says that the service is not medically necessary. Our physician reviewer found the member's prosthetist states that K3 microprocessor foot are indicated for member. The notes from member's physician show that member is K3 ambulator, but do not indicate why a microprocessor foot is reasonable and necessary. Further, member is involved with construction work. Notes do not show why mechanical foot, which is more durable than requested microprocessor foot, will not meet member's needs. While prosthetist states that microprocessor foot is medically necessary, the prosthetist is a vendor. While the prescription from the member's physician includes a microprocessor foot, there is no objective evidence in the medical record to show why a mechanical K3 foot cannot be used. 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 microprocessor foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor foot (K5973).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82570) provided March 18, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is 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. We find that CPT code 82570 is not supported in the medical record. Specifically, per the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter X, providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82570) provided March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (43255) provided to the enrollee on April 26, 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 CPT 43255 is considered inclusive to CPT 43239.
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 43255
has a bundled relationship with code 43239 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (43255) provided to the enrollee on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a conformis custom knee implant.
You asked the Plan to pre-approve a conformis custom knee implant. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 a conformis custom knee implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the conformis custom knee implant is experimental at this time. More research is needed to show safety and efficacy of the implant. The surgery may be safely and effectively performed with a non customed implant. 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 conformis custom knee implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a conformis custom knee implant.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Entyvio.
You asked the Plan to pre-approve Entyvio. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for Entyvio is correct, because the Plan requires a trial of Remicade or Inflectra and Stelara before it will approve Entyvio.
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 reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Entyvio. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Remicade or Inflectra and Stelara. The records do not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Entyvio.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain due to osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an echocardiogram.
You asked the Plan to pre-approve an echocardiogram. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an echocardiogram. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical necessity for echocardiogram has not been established in the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve an echocardiogram.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the electrocardiograms provided on March 17, 2020 and July 1, 2020.
You asked the Plan to waive the copayments for the electrocardiograms. You say that you met your maximum out-of-pocket amount and should not be charged the copayments. 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 $20 copayment for Medicare-covered non-radiological diagnostic services. For these dates of service, you have been asked to pay the allowed amounts of the claims because these amounts are less than the standard $20 copayment for the electrocardiogram.
You have been asked to pay a $14.48 copayment for the electrocardiogram on March 17, 2020 and a $14.41 copayment for the electrocardiogram on July 1, 2020. The electrocardiograms fall within "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you had only met $581.57 of the maximum out-of-pocket amount when the claims were processed.
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 the electrocardiograms provided on March 17, 2020 and July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381) for teeth # 4 and 11.
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says localized delivery of antimicrobial agents is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested localized delivery of
antimicrobial agents is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381) for teeth # 4 and 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 that the complexity of the enrollee's nursing, medical, and rehabilitation 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 1, 2021.
You asked the Plan to pay for eyeglass deluxe frames, progressive lenses and anti-reflective coating. You say that you were instructed by the Plan to see an out-of-network provider and told to submit forms with itemized bills. The Plan denied your request. The Plan says eyeglasses will only be covered when they are received from a provider in the specified vision network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider who participates in the Plan's specified vision network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network, therefore, the service is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglass deluxe frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this would be covered under Part D.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve a Botox injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two home health skilled nursing and nine physical therapy visits.
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 medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has been receiving home health services since March 22, 2021. The physical therapy note dated September 9, 2021, states she needs supervision for rolling, sitting up, lying down, standing up, and sitting down. She is walking 400 feet with a quad cane and assistance. The nursing note dated September 13, 2021 states she has no wounds. She has no skilled therapy or skilled nursing needs. She is functioning at a level that does not require continued home health services. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve two home health skilled nursing and nine physical therapy visits.