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

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Procrit. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has anemia with chronic kidney disease. The documentation does not support that the
enrollee has tried and failed Aranesp, Mircera or Retacrit. The documentation does not support an indication
that the plan's required drug(s) 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 Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta to be provided by an out-of-network (OON)
provider.
You asked the Plan to pre-approve Benlysta. You say that these services are medically necessary to control the
enrollee's lupus nephritis. The Plan denied your request. The Plan says the requested services can be provided
to the enrollee by a network provider.
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
Benlysta to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, topical application of fluoride varnish, and periodontal maintenance provided on June 21, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, topical application of fluoride varnish, and periodontal maintenance. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these services are not covered because the treating provider has chosen to opt out of the Medicare program.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, topical application of fluoride varnish, and periodontal maintenance provided on June 21, 2021 by a Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug test(s), 8-14 drug class(es), including metabolite(s) if
performed (CPT code G0481) provided to the enrollee on November 12, 2020.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the medical records do not contain documentation of definitive laboratory results for 8-
14 drug classes, including metabolites to support the coding criteria for G0481 for the billed date of service
November 12, 2020. The Plan states only six (6) drug classes were counted per laboratory results submitted.
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 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 testing. Our reviewer found the records do not
contain laboratory results for 8-14 drug classes, including metabolites to support G0481. Only six (6) drug
classes are on file.
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 testing have not been met. Therefore, we decided that the Plan does not
have to pay for drug test(s), 8-14 drug class(es), including metabolite(s) if performed (CPT code G0481)
provided to the enrollee on November 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) and lower leg x-ray, 2 views, (73950) provided on June 24, 2021.

You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) and lower leg x-ray, 2 views, (73950) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting provided on July 31, 2021.
You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan does not cover contact lens fitting as a routine eyewear benefit. Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on July 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Entyvio (J3380).  You asked the Plan to pre-approve Entyvio. You say that you believe treatment with Entyvio at this time is medically necessary and should be a covered and reimbursed service. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Entyvio.  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 Entyvio. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives, Remicade or Inflectra, and Stelara. Our reviewer also found that 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 alternatives.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. 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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary in this case. Our physician reviewer found that 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing aids provided on May 4, 2021.
You asked the Plan to waive the copayment for hearing aids. You say that you were misled by the doctor's
office and told that this provider was in-network. The Plan denied your request. The Plan says the claim
processed with correct copayment applied to the claim.
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.
We looked at the file and the Plan's rules. The file shows that the hearing aids were purchased from a provider
that is out-of-network and the claim processed with the correct copayment applied to the claim. Therefore, we
decided that the Plan does not have to waive the copayment for hearing aids provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on March 13, 2021.

You asked the Plan to reimburse you for hearing aids. You say that the Plan's hearing aid vendor's hearing aids did not work for you. The Plan denied your request. The Plan says hearing aids that are not provided by the Plan's hearing aid vendor's branded hearings aids are not covered under any condition.

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 obtained from the Plan's contracted hearing provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not obtained from the Plan's hearing provider. 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 March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes
(CPT code 99239) provided to the enrollee on February 20, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. CPT code 99239-GC is not billed as
per Medicare guidance. Therefore, we decided that the Plan does not have to pay for hospital discharge day
management; more than 30 minutes (CPT code 99239) provided to the enrollee on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic (CPT code 62321) provided to the enrollee on April 19, 2021, by an out-of-network provider.
You asked the Plan to pay for the injection. You say that you were unaware that prior authorization was required for services to be rendered by the out-of-network provider. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic (CPT code 62321) provided to the enrollee on April 19, 2021, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 31, 2020.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says in accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on December 31, 2020. The member's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for transtelephonic monitoring, pacemaker monitoring provided
on July 21, 2021.
You asked the Plan to pay for transtelephonic monitoring, pacemaker monitoring. The Plan denied your
request. 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 services were not referred by a network
provider or rendered in a participating facility. We have also determined that these services are not urgent or
emergent, nor were they approved in advance.
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 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 transtelephonic monitoring, pacemaker monitoring provided on
July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 19, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered services.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7140) and a dental consultation (D9310)
provided by an out-of-network provider on June 2, 2021, to June 30, 2021.
You asked the Plan to pay for a tooth extraction and a dental consultation. You say that you were never told
this doctor did not take Medicare. The Plan denied your request. The Plan says the rendering physician has
opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. The rendering physician has opted out of Medicare from April 20,
2017 to April 20, 2023. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7140)
and a dental consultation (D9310) provided by an out-of-network provider on June 2, 2021, to June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reimburse payment for the heavy-duty hospital bed and the extra heavy-duty wheelchair in a lump sum, and the sales tax applied to both provided on June 14, 2021, and June 18, 2021.  You asked the Plan to reimburse payment for the heavy-duty hospital bed and the extra heavy-duty wheelchair in a lump sum, and the sales tax applied. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says Medicare requires that durable medical equipment be in monthly rental reimbursements. The Plan says that as a result they are processing the first three months for reimbursement, however, monthly submissions of reimbursement for these items will be required until the 36-month rental period is exhausted, or the purchase price has been satisfied. The Plan also says that additional payment for sales tax is not payable by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that the total price of the equipment item is reported on the first bill and that monthly payments are made by the Plan. The monthly amount is equivalent to the rental fee schedule amount and is paid until the fee schedule purchase price or actual charge has been reached, whichever comes first. In this case, the Plan says they are processing the first three months for reimbursement, however, monthly submissions of reimbursement for these items will be required.  The rules also say that contractors do not make any additional payment for sales taxes. Therefore, we decided that the Plan does not have to reimburse payment for the heavy-duty hospital bed and the extra heavy-duty wheelchair in a lump sum, and the sales tax applied to both provided on June 14, 2021, and June 18, 2021.   Maximus Federal Services read your letter and knows that you may have a quality-of-care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality-of-care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on October 7, 2020.

You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.

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 ordered through the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing provider. 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 October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc (J7327).

You asked the Plan to pre-approve Monovisc. You say that the requested medication is necessary as the enrollee does not want to have surgery. The Plan denied your request. The Plan says for the request to be eligible for coverage under your medical benefit, the medication must be supplied by your provider or medical facility. The Plan also says that the medication is not covered when supplied by a pharmacy.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc (J7327).