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

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on January 12, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that as a former smoker, you are entitled to a free screening CT scan every year. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you do not meet criteria for the annual low-dose CT scan at no cost sharing.

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 $100 copayment for diagnostic radiology services. 

You have been asked to pay a $100 copayment for the CT scan. According to your contract, certain members are eligible for a low-dose screening CT scan every 12 months at no cost sharing. In order to qualify for coverage, you must be between 55 and 77 years of age. Records show that you are currently 83 years of age, so you do not qualify for this benefit. As a result, the CT scan you had is treated as a diagnostic radiology service for which a copayment applies. 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 computed tomography (CT) scan of the chest you had on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network wound care provider.

You asked the Plan to pre-approve these services. You say that the enrollee prefers to see this provider. The Plan denied your request. The Plan says the services are available from in-network providers.

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 a referral to an out-of-network wound care provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.
You asked the Plan to pre-approve massage therapy services. You say that nothing else has worked to help with the neck pain. You say that massage therapy is the last resort as the enrollee cannot use the medications. The Plan denied your request. The Plan says massage therapy is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the medical records provided support the need for the requested CGM. 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The medical records show that the enrollee uses insulin twice a day. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 HH PT visits (CPT code G0151 X16), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee remains at increased risk for fall. The Plan denied your request. The Plan says they previously approved visits to teach the enrollee a home exercise program. The Plan states the records suggest that continuing this exercise program should help the enrollee maintain their level of function or improve further. The Plan states the enrollee's records do not support the need for a skilled physical therapist to make more home visits at this time.
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 the services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented, ongoing, HH PT needs. The enrollee is mobilizing at a level consistent with their prior level of function. The enrollee has an available caregiver. The enrollee's care needs 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 HH PT visits (CPT code G0151 X16), for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.

You asked the Plan to pre-approve Prolia. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of zoledronic acid before it will approve Prolia.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 HH SN services (CPT code G0299 X4), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says eight (8) nursing visits have previously been approved to help the enrollee. The Plan states the enrollee's vital signs, taken by the home health nurse, are stable, their medical condition has not changed recently, the enrollee does not have any wounds that require nursing care, and the enrollee does not have any signs or symptoms of a bladder infection. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.

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 the services. physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e.: IVs, complex wound care, new ostomy). As such, the requested, ongoing, HH SN services are not medically necessary or reasonable. 

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 4 HH SN services (CPT code G0299 X4), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 7, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim 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 a physical therapy assistant (PTA) 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 physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee must have tried both oral and intravenous bisphosphonates (a group of medications used to prevent brittle bones) for 1 year and failed them or have a clinical reason why they cannot take them. The Plan also says that documentation was not submitted to show that the enrollee meets this criterion.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of both oral and intravenous bisphosphonates before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 HH SN services (CPT code G0299 x7), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's records show that their medical condition and medication management were reviewed with the enrollee. The Plan states the approved visit(s) should be enough to help the enrollee prepare for discharge and it is not likely that more skilled home nursing visits will be 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 the services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e.: IVs, complex wound care, new ostomy). As such, the requested, ongoing, HH SN services are not medically necessary or reasonable.

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 7 HH SN services (CPT code G0299 x7), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a phenylephrine/ketorolac ophthalmic solution (J1097) used during cataract surgery performed on July 7, 2021.
You asked the Plan to waive the coinsurance for eye irrigation solution. You say that you were told twice that each eye would cost $250, and you already paid that amount. You say you do not understand why you are still getting billed after contacting both the Plan and provider to confirm what you were originally told. The Plan denied your request. The Plan says the cost-sharing was applied correctly. The Plan states that the medical records show the medication was administered by the provider during the visit and is a covered medication under Medicare Part B. Furthermore, the Plan says that all covered Medicare Part B drugs require a 20% coinsurance under your contract.
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% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance in the amount of $80.80 for eye irrigation solution (Allowed Amount $404  20% = $80.80). The eye irrigation solution you received falls within the Medicare Part B Prescription Drugs 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 coinsurance for a phenylephrine/ketorolac ophthalmic solution (J1097) used during cataract surgery performed on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature 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 the request for initial prosthesis with microprocessor knee and K3 foot does not meet
Medicare criteria as reasonable and 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested items exceed the enrollee's medical need as the documentation does not support that this
enrollee is a level K3 ambulator given the documentation that the expected ambulatory aid will be a twowheeled
walker. Additionally, the documentation does not reveal that the enrollee is unable to meet his
functional needs with a mechanical knee over a microprocessor knee.
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 a prosthetic leg with an advanced knee/foot feature for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) tomographic (SPECT) (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that you ordered a nuclear stress test to rule out cardiac etiology of his chest tightness. His last nuclear stress test was in 2016. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for the requested MPI.
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 myocardial perfusion imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found on 10/6/2021 the enrollee complained of intermittent chest tightness. There were no physical exam findings and no reported EKG changes. The enrollee has no known history of cardiac disease. There was no specific clinical rationale for the requested myocardial perfusion imaging, tomographic (SPECT) (78452). The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) tomographic (SPECT) (78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for mouth surgery provided on August 11, 2021.
You asked the Plan to waive the deductible for outpatient surgery. You say that this was medically necessary. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,500 deductible which applies to out-of-network outpatient surgery. At the time this claim was processed, $0 of the $1,500 deductible had been met. The allowed amount of this service is $330, resulting in a deductible amount of $330. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,500 deductible which applies to Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was received on August 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for mouth surgery provided on August 11, 2021.
Please note that the dental anesthesia service billed on this claim (D0140) has been processed and paid by your dental benefits as opposed to the medical benefits which covered the mouth surgery. Please contact the Plan or your dental plan for more information about the payment of code D0140.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from August 6, 2021, to August 12, 2021.

You asked the Plan to pay for the services. You say that the enrollee revoked Hospice on July 31, 2021. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on August 7, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided from August 6, 2021, to August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the cost share of a periodic oral evaluation (D0120) and a prophylaxis cleaning (D1110) provided on August 31, 2021.
You asked the Plan to hold you harmless for the cost share of a periodic oral evaluation and a prophylaxis cleaning. You say that you are seeking reimbursement of $42. You also say the Plan's literature says nothing about needing to use a participating dentist to receive dental cleanings. The Plan denied your request. The Plan says that the Plan paid up to the agreed amount on the claim for an out of network provider.
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 two preventative evaluations and two cleanings per year. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and a prophylaxis cleaning have been met. Specifically, the dental contract clearly lists that preventative evaluations and cleanings are a covered benefit with an in-network or out of network provider. The Plan has not submitted any documentation showing that if the enrollee chooses to see a non-participating dentist, and if the dentist charges more than the Plan agreement, the enrollee is responsible for the difference. Therefore, we decided that the Plan has to hold you harmless for the cost share of a periodic oral evaluation (D0120) and a prophylaxis cleaning (D1110) provided on August 31, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter