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

We decided that the Plan does not have to pay for injection services provided to the enrollee on September 17, 2020.
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 services are included in the nutri-pharmaceutical blend/mix and are not separately reported.
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: HCPCS J1955: Injection, levocarnitine, per 1 gm HCPCS J3411: Injection, thiamine hcl, 100 mg
HCPCS J3415: Injection, pyridoxine hcl, 100 mg HCPCS J3490: Unclassified drugs 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the services were incorrectly billed. The various drugs were blended to create a nutria-pharmaceutical blend/mix. Each medication blended/mixed should not be reported separately. Providers should indicate the drug is compounded and include the drug name and total dosage given for each drug. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on September 17, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips
You asked the Plan to pre-approve the additional trips. You say that more transportation is needed for dialysis
appointments. The Plan denied your request. The Plan says the benefit only allows 60 trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (96365, 96366, 96375, J2310, J2704, J7040) provided May 7, 2021.
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed codes.
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 codes 96365, 96366, 96375, J2310, J2704, and J7040 are not supported in the medical record. Specifically, the documentation does not include enough information to verify units billed. Documentation should include route of administration and dosage to calculate units billed. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96375, J2310, J2704, J7040) provided May 7, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc, Monovisc, or Synvisc/Synvisc One first.
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 Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not trialed a viscosupplemental treatment such as Orthovisc, Monovisc, or Synvisc/Synvisc-One. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not approved as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 August 14, 2021.
You asked the Plan to pay for the limited oral exam to evaluate a problem. You say that your two exams were
nothing alike. 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 limited
oral exam to evaluate a problem once per plan year.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that a limited
exam to evaluate a problem was previously covered on July 6, 2021.
Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam to
evaluate a problem has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited
oral evaluation - problem focused (D0140) provided August 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latanoprost (J3490).
You asked the Plan to pre-approve Latanoprost. You say that the enrollee has been treated with Latanoprost for
more than 8 years. The Plan denied your request. The Plan says this drug is not covered for the enrollee'
condition by Medicare Part B.
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 Latanoprost (J3490).
Benefits for Latanoprost 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says this is considered experimental and investigational.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that this procedure is experimental. More research is needed.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for conductive garments for Transcutaneous Electric Nerve
Stimulation (E0731) provided June 21, 2021.
You asked the Plan to pay for the conductive garments for Transcutaneous Electric Nerve Stimulation. You say
that the items were medically necessary. The Plan denied your request. The Plan says the number of units
billed is not supported by the provided records.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 3.
The MAI value for this code is 3. The number of units billed exceeds the MUE. The documentation does not
include the required information to determine the medical necessity for coverage of the number of units billed.
Based on this information, we decided that Medicare rules for coverage of the conductive garments for
Transcutaneous Electric Nerve Stimulation have not been met. Therefore, we decided that the Plan does not
have to pay for conductive garments for Transcutaneous Electric Nerve Stimulation (E0731) provided June 21,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third treatment with Zilretta injection.
You asked the Plan to pre-approve Zilretta. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Zilretta. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Zilretta is not Food and Drug Administration-approved for the enrollee's diagnosis. The Medicare-approved major drug compendia and the manufacturer's prescribing information for Zilretta state that "the efficacy and safety of repeat administration of Zilretta have not been demonstrated." We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve a third treatment with Zilretta injection.
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 this is medically necessary. The Plan denied your
request. The Plan says this is 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 you are medically stable and do not meet the coverage criteria for this admission.
With your current medical stability, and no other medical complexity, there is no need for physician
supervision three times per week (at a minimum) for the ongoing management of any active or acute
exacerbations of chronic medical conditions. There are no acute rehabilitation or nursing needs. At your current
functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least
5 days per week with multidisciplinary approach to daily therapy. There are no acute neurological deficits.
Rehabilitation needs can be safely met in an alternate and lower intensity setting, such as skilled nursing
facility.
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 Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the step therapy
criteria have not been 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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically reasonable and necessary in this case. Our physician reviewer found that the
record indicates that the enrollee has osteoarthritis of the knee. The requested medication is considered a new
start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse
effect from the plan's preferred step one alternative.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injections.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not a
covered service.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient high-quality evidence to
justify the use of PRP for the treatment of any condition except for within the confines of a well-designed
clinical trial.
We looked at the file and Medicare rules. The requested PRP injections are non-covered, per L38937, except
when provided within a clinical trial. The submitted documentation does not indicate that the enrollee is
enrolled in a clinical trial. Based on this information, we decided that Medicare rules for coverage of the
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet rich
plasma (PRP) injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug injection provided on May 17, 2021.
You asked the Plan to pay for the drug injection. You say that the provider has been paid previously for all the same procedure codes. You say that non-payment is not justified, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says CPT Codes 62370, J3010 and G0162 have been reprocessed and paid. The Plan also says that CPT Code J3490 remains denied as it is not able to be validated.
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 J3490 is drugs unclassified injection.
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 the drug injection. Our reviewer says that the documentation was reviewed and does not meet criteria for coverage. Our reviewer found that the documentation does not support the unclassified injection given therefore, the procedure cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug injection have not been met. Therefore, we decided that the Plan does not have to pay for the drug injection provided on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vaporization of the basivertebral nerve (Intracept) for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this procedure is experimental. More research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve vaporization of the basivertebral nerve (Intracept) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010).
You asked the Plan to pre-approve the surgical implant placement (D6010). The Plan denied your request. The Plan says the service 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 the surgical implant placement (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown, prefabricated post and core, and endodontic
therapy.
You asked the Plan to pre-approve the crown, prefabricated post and core, and endodontic therapy. The Plan
denied your request. The Plan says the services 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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
crown, prefabricated post and core, and endodontic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management services (procedure code 99217) provided to the enrollee on June 19, 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 the procedure code was not correct for the services or date of service billed.
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 99217 is "Observation care discharge day management." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found in order for CPT 99217 to be considered for reimbursement, an initial observation care CPT code must also be submitted. Because there is not initial observation care CPT code billed to the health plan relating to CPT 99217 on June 19, 2021, 99217 billed for June 19, 2021 is not eligible for reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management services (procedure code 99217) provided to the enrollee on June 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care