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

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary. The provided notes do not clearly show that the patient had tried and failed Orthovisc, Synvisc, or Synvisc-One for her knee osteoarthritis. The preferred agents would not be less effective or cause more adverse effects compared to Euflexxa as they are clinically equivalent in safety and effectiveness according to current comparative studies. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical extraction (D7210) provided on October 14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that 
your benefit plan covers tooth extractions. You also say that your tooth under the crown was decaying and the 
extraction was necessary. The Plan denied your request. The Plan says the problem focused limited oral 
evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that your lability was 
applied correctly per your plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 9, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. You are also responsible for the difference between the billed amount and 
allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation (D0140) and surgical extraction (D7210) 
provided on October 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out-of-network (OON) provider on September 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out-of-network (OON) provider on September 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. The Plan denied your request. The Plan says this drug is not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Aduhelm. Our reviewer says that
Aduhelm is not medically reasonable and necessary in this case. Our physician reviewer found that the
documentation is insufficient to demonstrate that Aduhelm is reasonably expected to be at least as beneficial as
existing and appropriate and available medically appropriate alternatives for this enrollee, and be both safe and
effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aduhelm.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography, thorax (71250) provided September 1, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you were referred to a pulmonary specialist for a lung scan and was diagnosed with COPD in both lungs. Another lung scan was ordered 30 days later and you believe this should be covered. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $85 for covered radiological diagnostic services, not including x-rays. You have been asked to pay $85 for the diagnostic service. The diagnostic service falls 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 computed tomography, thorax (71250) provided September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this procedure is medically 
necessary and reasonable. 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 for epidural steroid injections to be medically 
reasonable and necessary, patients should be part of an active rehabilitation program, home exercise program or 
functional restoration program. 
 
We looked at the file and Medicare rules. There is no evidence provided that the enrollee is currently in an 
active rehabilitation program, home exercise program or functional restoration program. Based on this 
information, we decided that Medicare rules for coverage of epidural steroid injection services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection services.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy. You would benefit from physical 
therapy and occupational therapy in a less intense setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
19, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were charged much less for 
previous injections. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs, including injectable drugs. 
 
 
 
  
You have been asked to pay $375, which is 20% of the allowed amount for the injection ($1,875 allowed 
amount x 20% coinsurance = $375). The file shows that during your previous injections, you were incorrectly 
charged coinsurance for the drug administration instead of the drugs itself. The Plan has not made any 
indication that these claims would be reprocessed. The injection 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 denosumab injection provided 
on March 19, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you continue to have a need for custodial care; however, the documentation doesnt 
support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional 
status. You can receive further services 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on October 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76705 is ultrasound, abdominal, real time with image 
documentation; limited (e.g., single organ, quadrant, follow-up). We find that CPT code 76705 may be eligible 
for payment when billed with CPT code 93976. The claim does not show that the code at issue was appended 
with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
abdominal ultrasound provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve obstetrics and gynecology (OBGYN) consultation to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an OBGYN consultation. You say that the out-of-network provider provides 
a special type of treatment that is needed. The Plan denied your request. The Plan says an approved in-network 
provider has been given to the enrollee that gives the same treatment of service as an out-of-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 
obstetrics and gynecology (OBGYN) consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (24301) provided on September 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 24301 is "Muscle or tendon transfer, any type, upper arm 
or elbow, single (excluding 24320-24331)". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 24301 is 
not supported by the records provided.  Our reviewer found that the operative report documents "Nerve released posteriorly without damage to the 
vasculature, Intermuscular septum released proximal to the medial epicondyle. Z-lengthening at the fascia 
performed in trough into the muscle was cut. Nerve transposed and Z-lengthening fascia repaired over the 
nerve and sutured in place with Vicryl suture. Tension was checked and no pressure on the nerve under the 
fascia." The documentation does not support that there was relocation of uscle or tendon of upper arm or 
elbow. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (24301) provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
(98941) and mechanical traction (97012) provided June 23, 2021 
 
You asked the Plan to waive the copayment for the chiropractic service. You say that please reimburse the 
share you are eligible for. The Plan denied your request. The Plan says the claim was processed with the correct 
copayment applied per the Evidence of Coverage. 
 
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 $20 
copay for each Medicare covered visit for Chiropractic services.  
 
 You have been asked to pay $55 ($20 + $35) for the chiropractic service. Mechanical traction is not covered 
under the Plan benefits. The service falls within the Chiropractic services 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 the chiropractic manipulative treatment (98941) and mechanical 
traction (97012) provided June 23, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Vertiflex device is experimental. More research is needed. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee has an ovarian mass that needs to 
be evaluated by an oncologist. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on September 
10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the procedure code billed is not correct for 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 looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a 
single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel testing 
provided on September 10, 2021.