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

We decided that the Plan does not have to pre-approve the expandable controller (E2377) and expandable
controller harness (E2313).
You asked the Plan to pre-approve the upgraded electronics. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says there are three approved power
options on the approved wheelchair and there is no medical need to control these power options through the
joystick. Therefore, the upgraded electronics are not medically necessary.
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 upgraded electronics. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee lives alone and has difficulty transferring on his own and has back pain
when sitting upright for prolonged periods of time and a reclining option was requested and approved. The
expandable controller and harness was however, not justified and do not meet Medicare criteria for this
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan
does not have to pre-approve the expandable controller (E2377) and expandable controller harness (E2313).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can have the care you need at home with home health care or at an alternative level of care within the nursing home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral periapical x-rays (D0220 and D0230), and bitewing x-rays (D0274) provided on May 19, 2021.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, and bitewing x-rays. You say that when you contacted the Plan prior to receiving these services, you were advised by the representatives that you were qualified and approved for the services that were to be rendered. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded. The Plan also says that during your calls with the Plan, you were provided with no misinformation and neither benefits nor eligibility for specific procedures were discussed.
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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years and intraoral x-rays (D0220 and D0230) and bitewing x-rays (D0274) are each limited to one procedure code per calendar year. The record shows that you received a comprehensive oral evaluation (D0150) on July 2, 2020, and an intraoral periapical x-ray (D0220) and bitewing x-ray (D0270) on April 19, 2021, and your comprehensive oral evaluation, intraoral periapical x-rays, and bitewing x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral periapical x-rays (D0220 and D0230), and bitewing x-rays (D0274) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care supervision (99379) provided on March 31, 2021.
You asked the Plan to pay for the nursing facility care supervision. You say that you would like reconsideration because this provider rendered medically necessary services in good faith. The Plan denied your request. The Plan says payment for this service is always bundled into another service.
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 99379 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes. We find that CPT code 99379 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99379 has a status indicator of B. This means that the payment for CPT code 99379 is always bundled into another service. Based on this information, we decided that Medicare rules for coverage of the nursing facility care supervision have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility care supervision (99379) provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for coronary artery disease testing (81493) provided on June 16, 2020.
You asked the Plan to pay for coronary artery disease testing. You say that this is a covered service and was billed correctly. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of coronary artery disease testing have not been met. Therefore, we decided that the Plan does not have to pay for coronary artery disease testing (81493) provided on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthodesis (27279).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have not had clear documentation of intensive non operative treatment for 6 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Not enough conservative measures have been tried and failed. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 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 arthodesis (27279).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aa magnetic resonance imaging (MRI) of the left knee.

You asked the Plan to pre-approve an MRI of the left knee.. You say that this MRI is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the left knee. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the review indicates that the enrollee is a 50-year-old female with a history of asthma, gastroesophageal reflux disease, and depression. She has complained of left knee pain. Her provider has recommended an MRI of the left knee. The review indicates that the records show you were seen by her provider on September 7, 2021. Records did not show she had a new complaint, or a change in the previous complaint. There is no documentation of ligament instability on exam. Records did not show that an X-ray was obtained before the MRI was ordered. The requested service is not 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 an MRI of the left knee. have not been met. Therefore, we decided that the Plan does not have to pre-approve aa magnetic resonance imaging (MRI) of the left knee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine (J8597).
You asked the Plan to pre-approve Promethazine. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Promethazine (J8597).
Benefits for Promethazine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-area provider. 
 
You asked the Plan to pre-approve the requested services. You say that you need to begin regaining the use of 
the left side of your body. The Plan denied your request. The Plan says occupational therapy is available in the 
service area with network providers. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
The file shows that 36 visits were requested. The plan has agreed to pre-approve 6 visits. We looked at the file, 
and Medicare rules. There is no evidence that shows additional care is needed at this time beyond what was 
approved by the plan. Additional services may be approved after the results of the approved treatment has been 
reviewed. Based on this information, we decided that Medicare rules for coverage of the requested services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve occupational therapy 
services to be provided by an out-of-area provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on April 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, prophylaxis, and topical application of fluoride varnish. You say that you should pay a $0 copay for cleanings, x-rays, and fluoride treatments. You also say that preventive dental care is covered in-network and out-of-network. The Plan denied your request. The Plan says the total $210 amount applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on April 16, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the enrollee has failed Methotrexate, Calcipotriene, and topical steroids. The Plan denied your request. The Plan says the enrollee has not tried and failed treatment with Remicade, Inflectra, or Stelara.
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 Ilumya. Our physician reviewer found that the enrollee has moderate to severe plaque psoriasis. The Plan requires a trial of Remicade, Inflectra or Stelara before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less effective or likely have adverse effects for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the plunger switch (K0108), modify AFP independent simultaneous (K0108), and footplate bracket (K0108).

You asked the Plan to pre-approve the plunger switch, modify AFP independent simultaneous, and footplate bracket. You say that the items are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.

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 the plunger switch (K0108), modify AFP independent simultaneous (K0108), and footplate bracket (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Prolia for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that this is medically necessary. The Plan denied your request. The Plan says that tiering exceptions are not available for drugs covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), prophylaxis 
(D1110), and topical application of fluoride varnish (D1206) provided on April 7, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and topical application of fluoride 
varnish. You say that you were not aware that the treating provider was not in-network. The Plan denied your 
request. The Plan says your OON liability was applied correctly per your plan 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, you are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we 
decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and topical application of fluoride varnish (D1206) provided on April 7, 2021 by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 10, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 out-of-network physician services provided to the enrollee on May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on December 10, 2019.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-area provider.
You asked the Plan to pre-approve the requested services. You say that you need therapy to regain use of the left side of your body. The Plan denied your request. The Plan says services are available in the service area with network providers.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file, and Medicare rules. The file shows that the Plan has approved 6 treatment visits for rehabilitation after a stroke. Additional services cannot be approved until the results of the approved treatment has been reviewed. There is no evidence that shows additional care is needed at this time beyond what was approved by the plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-area provider.