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

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the enrollee was non-compliant with oral medications. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid.
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 necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, zoledronic acid. The reviewer also found that the documentation does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria has 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 Prolia have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from April 10, 2019 to April 22, 2019.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of diagnosis code I25.10.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code I25.10 (atherosclerotic heart disease of native coronary artery without angina pectoris). 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 pay for these services. Our reviewer says that the submitted records do not support the billing of diagnosis code I25.10. Our physician reviewer found while the documentation of vasodilatory shock was noted on the critical care progress note and in theprovider query, other documentation evidence was unclear, incomplete, and conflicting regarding this condition. The records further support an admission for further evaluation and treatment of non-ST elevated myocardial infarction (NSTEMI) for which a coronary artery bypass graft (CABG) was performed. The record is incomplete to reflect hemodynamic instability, inability to wean from routine pressor administration post cardiopulmonary bypass, signs or symptoms of decreased peripheral circulation or urinary output and patient was successfully liberated off mechanical ventilation within six hours of surgery. Diagnosis code I25.10 is not supported.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from April 10, 2019 to April 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cinacalcet rendered on March 2, 2021 to June 29, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that all drugs and biologicals used for the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS and are not separately paid as of January 1, 2011.  We looked at the file and Medicare rules. The file shows that the drug was used in the treatment of ESRD. Payment for these services is included in the ESRD payment. Therefore, we decided that the Plan does not have to pay for the Cinacalcet rendered on March 2, 2021 to June 29, 2021.
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 5, 2021.  You asked the Plan to pay for the limited oral exam. You say that this service was necessary, and you would like it to be covered. 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 once per plan year.    We looked at the file and Medicare rules. A limited exam was previously covered by the Plan on May 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for compression stockings (A6545) provided on May 14, 2021, and May 19, 2021.  You asked the Plan to pay for compression stockings. You say that a representative of the Plan told you that the claim would be paid. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the items at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.     Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for compression stockings (A6545) provided on May 14, 2021, and May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the oncology office visits you had on July 21, 2021, and August 4, 2021.  You asked the Plan to waive the copayments for the oncology office visits. You say that you met your out-of-pocket maximum for the year, so you should not have these copayments. The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that you originally met your out-of-pocket maximum in March of this year.  However, the March claim was later adjusted, reducing your out-of-pocket maximum by $1544.72.  That means that for the dates of service in this appeal, you had not yet met your out-of-pocket maximum.  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 $50 copayment per visit for specialist office visits.   You have been asked to pay a $50 copayment per visit for the oncology office visits. The oncology office visits fall within the specialist office visits 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 copayments for the oncology office visits you had on July 21, 2021, and August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (80076, A4930) provided on December 29, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 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, we have confirmed that code 80076 is a column II code to column I code 80053. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code A4930 is 0. You billed 1 unit of this code, exceeding the MUE. 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 the services (80076, A4930) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup (D2950) provided on August 6, 2021, and August 9, 2021.  You asked the Plan to pay for the core buildup (D2950). You say that if this procedure wasn't performed you could have lost your teeth. You say that you have been in a financial hardship and these funds should be paid. The Plan denied your request. The Plan says this service has to be performed together with a crown.  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, core buildup has to be performed together with a crown to be covered. The records show that a crown was not billed on either date of service at issue. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950) provided on August 6, 2021, and August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anti-reflective lens coating provided on April 20, 2021.  You asked the Plan to pay for the anti-reflective lens coating. You say that you returned later to add the anti-reflective lenses to your glasses. You say that you couldn't see well without the anti-reflective treatment and you should be reimbursed the additional expense. The Plan denied your request. The Plan says additional lens options are not covered.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only standard lenses are covered in full.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective lens coating have not been met. Specifically, lens upgrades are not covered. Therefore, we decided that the Plan does not have to pay for the anti-reflective lens coating provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a spinal orthosis (L0650) provided to the enrollee on January 11, 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 there was no specific physical examination of the back.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to support that this orthosis was reasonable or necessary in this case. The documentation does not support that this orthosis was ordered for one of covered indications in the guidelines. The documentation does not include an examination of the back. An x-ray of the lumbar spine was ordered, but the results of this x-ray were not included in the records.  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 pay for a spinal orthosis (L0650) provided to the enrollee on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interspinous process fusion device (Minuteman procedure).  You asked the Plan to pre-approve Minuteman procedure. You say that this will help with quality of life and reducing pain medications. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there are not enough studies showing that Minuteman is safe and effective.  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 Minuteman procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous process fusion device (Minuteman procedure).
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 you are in danger at home. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.  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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve land based physical therapy.  You asked the Plan to pre-approve land based physical therapy. You say that the physical therapy is medically necessary. The Plan denied your request. The Plan says the enrollee can only participate in one service at a time. Once the enrollee is able to tolerate land-based exercises, then your provider can resubmit for review. Aquatic therapy exercises should be used to facilitate progression to land based therapy and to increased function.  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 land based physical 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond the aquatic therapy that was approved by the health Plan. The enrollee continues to undergo aquatic therapy. The records do not demonstrate at this time that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist for land based therapy without the outcome of aquatic therapy. The enrollee continues to have deficits despite undergoing pool therapy and has not completed her total approved aquatic therapy yet. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of land based physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve land based physical therapy.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve omeprazole capsules.  You asked the Plan to pre-approve self-administered drug. 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 this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 omeprazole capsules.   Benefits for self-administered drug 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 the laboratory services rendered on July 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 2. In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 2. You billed 8 units of this code, exceeding the MUE. 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 pay for the laboratory services rendered on July 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-help, peer services, per 15 minutes (H0038) provided on May 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the self-help, peer services. You say that you have been seeing this provider for your recovery and feel that this should be covered under your chemical dependency benefit. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 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 the self-help, peer services, per 15 minutes (H0038) provided on May 12, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions.  You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is medically necessary and would be beneficial for you. The Plan denied your request. The Plan says the criteria for additional physical therapy sessions are not met, and therefore the requested services are not medically necessary.  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 physical 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 that the additional therapy requested is not generally accepted as specific and effective therapy for your condition beyond what was previously approved by the health plan. You have had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have had prior instruction in a home exercise program (HEP) and report some completion of your HEP. The therapist's note states you have poor HEP completion. The requested services are not part of a maintenance program, and do not require the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on June 14, 2021, to June 28, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.   We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on June 14, 2021, to June 28, 2021.