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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that due to member's medical condition it is required 
to have continued supervision by medical staff as no one will be home to take care of the member. The Plan 
denied your request. The Plan says that the enrollee does not require daily skilled therapy services. 
 
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 the enrollee's condition does not 
meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network rest home visit services provided to the enrollee on June 3, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network rest home visit services provided to
the enrollee on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nasal/Sinus endoscopy procedure to include a sphenoidectomy and ethmoidectomy (31287, 31253) 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 the clinical value and effectiveness of a nasal/sinus endoscopy sphenoidectomy and ethmoidectomy in the setting of a normal CT scan of the ethmoid and sphenoid sinuses has not been demonstrated in the peer-reviewed literature.
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 documentation does not support that endoscopic sinus surgery of the ethmoid and sphenoid sinuses is medically reasonable
and necessary for the enrollee in this case. The computed tomography (CT) scan does not support the presence of disease in the ethmoid and sphenoid sinuses. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 Nasal/Sinus endoscopy procedure to include a sphenoidectomy and ethmoidectomy (31287, 31253) for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 pm and 8:00 am at a 24-
hour facility (99053) provided on June 1, 2021. 
 
You asked the Plan to pay for services provided between 10:00 pm and 8:00 am at a 24-hour facility. You say 
that you would like these claims reprocessed for payment. The Plan denied your request. The Plan says the 
claim for this service has denied correctly. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B meaning that payment for this service is always bundled into another procedure. Separate 
payment is not made for CPT code 99053. Based on this information, we decided that Medicare rules for 
coverage of services provided between 10:00 pm and 8:00 am at a 24-hour facility have not been met. 
Therefore, we decided that the Plan does not have to pay for services provided between 10:00 pm and 8:00 am 
at a 24-hour facility (99053) provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammography and 
tomosynthesis of both breasts (77066, G0279) provided by an in-network provider on July 7, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you were diagnosed 
with breast cancer in 2016 and were told you would need to have diagnostic mammograms for five years 
following treatment. You say that the first four years were covered and paid in full and want to know why this 
fifth one is not. The Plan denied your request. The Plan says the claim was processed correctly toward your 
radiology benefit as diagnostics. 
 
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 $75 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $75 copayment for a diagnostic mammogram (77066). You have also been asked 
to pay a $25.34 copayment for a diagnostic tomosynthesis (G0279). The Plan's Allowed Amount for this 
service is less than the required $75 copayment. A diagnostic mammogram and tomosynthesis falls within the 
Outpatient Hospital Services benefit category because the service took place in an outpatient hospital setting. 
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 a diagnostic mammography and tomosynthesis of both 
breasts (77066, G0279) provided by an in-network provider on July 7, 2021.  
 
Please note: the Plan indicated you were charged a 40% coinsurance; however, we have verified you 
were not charged a coinsurance. The "Your Share" section on the Explanation of Benefits processed on July 
12, 2021, clearly states a copayment was applied.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit option (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is an accessory for outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit option (K0108) for a power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided March 1, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical records. 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 CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided March 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas treatment provided on November 30, 2020. 
 
You asked the Plan to pay for Sanexas treatment. You say that this procedure has been classified as a 
breakthrough in pain management treatment and is supported by peer-reviewed literature. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these services were not 
medically necessary and/or not supported by peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy 
services only if they are furnished by or under the direct supervision of a physical therapist in private practice, 
or by or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA 
may perform physical therapy services under state law. Medicare rules state that claims for compounded drugs 
shall be submitted using a compounded drug not otherwise classified code. 
 
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the 
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide 
physical therapy in the State of Arizona. The multiple drug codes reported on this claim refer to a pre-filled 
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. 
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on 
this information, we decided that Medicare rules for coverage of Sanexas treatment have not been met. 
Therefore, we decided that the Plan does not have to pay for the Sanexas treatment provided on November 30, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network coverage of chiropractic care to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve
in-network coverage of chiropractic care to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a genicular nerve block (64454) provided on June 15, 2021.
You asked the Plan to pay for a genicular nerve block. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the services at issue are experimental/investigational.
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 a genicular nerve block.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that genicular nerve blocks are considered experimental/investigational in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for a genicular nerve block (64454) provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. 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 Durolane. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline 
contraindications or reasons these medications were not considered or that the plan's additional required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a V2 dynamic arm support.
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says for durable medical equipment to be covered, it must primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a V2 dynamic arm support
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reacher/grabbing device.
You asked the Plan to pre-approve a reacher/grabbing device. You say that you do not walk and cannot bend to grab anything. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a reacher/grabbing device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for collection and application of autologous blood concentrate product (D7921) provided by a participating provider on July 7, 2021.
You asked the Plan to pay for collection and application of autologous blood concentrate. You say that you do not know why you are being charged so much for this. The Plan denied your request. The Plan says this is not a covered benefit.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for collection
and application of autologous blood concentrate product (D7921) provided by a participating provider on July 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the laser treatment services provided on May 14, 2021.
You asked the Plan to pay for the laser treatment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pay for the laser treatment services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the services rendered were not considered cosmetic surgery services. Excimer laser is a standard therapy for vitiligo. Therefore, the enrollee met criteria for the services rendered. 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 laser treatment services have been met. Therefore, we decided that the Plan has to pay for the laser treatment services provided on May 14, 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