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

We decided that the Plan does not have to pay for an x-ray (71045) provided May 2, 2021.

You asked the Plan to pay for the x-ray. You say that the services were not medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 

We find that CPT code 71045 is not supported in the medical record. Specifically, the claim was billed with an outpatient place of service (22). The record shows the enrollee was an inpatient at the time services were rendered. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided May 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay provided from March 11, 2021,
through March 22, 2021.

You asked the Plan to pay for the inpatient hospital stay. The Plan denied your request. The Plan says services
rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of
Coverage.

We decided that the Plan does not have to pay for an inpatient hospital stay provided from March 11, 2021,
through March 22, 2021.
You asked the Plan to pay for the inpatient hospital stay. The Plan denied your request. The Plan says services
rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of
Coverage.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an inpatient hospital stay provided from March 11, 2021, through
March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 19,
2021.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were
for your annual wellness exam and 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 $10
copayment for laboratory services.
You received laboratory services on May 19, 2021. Laboratory services are not included annual wellness
exams. Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the
outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve a genicular nerve block. You say that the requested genicular nerve block is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block is 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 a genicular nerve block. Our reviewer says that the requested genicular nerve block is not medically necessary. Our physician reviewer found the enrollee is diagnosed with right knee osteoarthritis and painful right knee status post right total knee arthroplasty (TKA) (2019). She is also status post left TKA (2016) and status post right total hip arthroplasty (2016). Her provider has recommended a genicular nerve block for the treatment of her right knee pain status post right TKA. 

Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 

The review has determined that the genicular nerve blocks are considered experimental/investigational in nature. The requested genicular nerve block 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 a genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional Occupational Therapy services.

You asked the Plan to pre-approve the additional Occupational Therapy. You say that you would like
reconsideration because the additional therapy is medically necessary. The Plan denied your request. The Plan
says the member does not require the unique skills of a therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional Occupational Therapy.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the requested therapy visits are not
medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the additional Occupational Therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve 24 additional Occupational Therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity autoinjectors.

You asked the Plan to pre-approve the Trulicity autoinjectors. You say that this medication is needed to treat the enrollee's condition. The Plan denied your request. The Plan says this drug is self-injected and is not covered 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 Trulicity autoinjectors.

Benefits for the Trulicity autoinjectors 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 19, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

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) code. 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.

You asked the Plan to pre-approve the Prolia treatment. You say that Prolia is necessary to treat the enrollee's bone density. The Plan denied your request. The Plan says bisphosphonates must be tried before coverage of Prolia is allowed.

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 the Prolia treatment. Our reviewer says that the requested drug is not reasonable and necessary based on the Plan's step therapy rules. Our physician reviewer found the Plan requires a trial of oral and intravenous bisphosphonates before they will approve the requested drug, Prolia. There is no evidence of a trial of these drugs. Based on the medical records provided, there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. 

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 Prolia treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.

You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the requested inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved surgery is 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 an inpatient level of care for the approved surgery. Our reviewer says that the requested inpatient level of care for the approved surgery is not medically necessary. Our physician reviewer found the Plan approved an elective total shoulder arthroplasty (23472). The shoulder replacement surgery may be safely performed with a 48-hour observational stay. Inpatient admission is not 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 an inpatient level of care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).

You asked the Plan to pre-approve bone marrow aspiration (20939). You say that the requested bone marrow aspiration (20939) is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration (20939) is 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 bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration (20939) is not medically necessary. Our physician reviewer found the enrollee is approved for inpatient surgery for L2/pelvis decompression/fusion. Bone marrow aspiration remains experimental for use as bone graft material in spinal surgery. More research is needed. The requested bone marrow aspiration is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service coded 99354 provided on March 10, 2021.

You asked the Plan to pay for the prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service. 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, the CPT Code Manual definition of code 99354 is prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]).

We find that CPT code 99354 is not supported in the medical record. Specifically, this code is an add-on code. This code was not billed with a primary procedure code. This means that this code is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service coded 99354 provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on April 22, 2021.

You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says you
purchased hearing aids outside of your Plan hearing aid benefit coverage.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by the Plan's hearing aid vendor.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aids
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids
provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee covers (A4467) provided May 26, 2021 to May 27, 2021.

You asked the Plan to pay for the knee covers. You say that the knee covers were medically necessary. The Plan denied your request. The Plan says the items at issue are not covered.

The Plan must follow Medicare rules. Medicare rules say that for a knee brace to be covered by Medicare, the brace must be a rigid or semi-rigid device. 

We looked at the file and Medicare rules. The support garments at issue are not rigid or semi-rigid devices and are therefore non-covered. Based on this information, we decided that Medicare rules for coverage of the knee covers have not been met. Therefore, we decided that the Plan does not have to pay for knee covers (A4467) provided May 26, 2021 to May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to be released to an IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care

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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for routine, non-emergency transportation.
You asked the Plan to provide coverage for routine, non-emergency transportation. You say that the enrollee is not able to drive due to multiple ongoing chronic conditions. You say the enrollee has exhausted all other options for transportation to medical appointments. The Plan denied your request. The Plan says the enrollee's Plan product does not provide transportation services.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The file shows that the enrollee's Plan product does not cover a routine, non-emergency transportation benefit. Therefore, we decided that the Plan does not have to provide coverage for routine, non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 20,
2021.

You asked the Plan to pay for the dental service. You say that the initial appointment was to obtain a
prescription to replace a crown. You say that the appointment consisted of x-rays and examination. You say
that the examination was not as thorough. You also say that both exams were necessary to safely perform the
extractions. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The
Plan also says that the frequency limit has been exceeded.

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 and limited oral evaluation is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for the limited oral
evaluation that you received on May 4, 2021.

The record shows that the Plan received the claim for May 4, 2021, prior to the claim for the date of service in
this case. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140)
provided on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 40 one-way trips per year.

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 40 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used 41 one-
way transportation trips this year. 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 provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you cannot afford new dentures and would like the Plan to make an exception. The Plan denied your request. The Plan says you have exceeded the frequency limit for the requested 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 one complete upper denture every five plan years. We looked at the file, and Medicare rules. The Plan provided documentation showing that a complete upper denture was previously covered on September 18, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).