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

 We decided that the Plan does not have to pre-approve Nurtec tablet, 75 mg.  You asked the Plan to pre-approve Nurtec. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 Nurtec tablet, 75 mg.   Benefits for Nurtec 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on July 20, 2021.  You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 (eg, single organ, quadrant, follow-up).  We find that CPT code 76705 is not supported in the medical record. Specifically, the documentation shows that the enrollee was inpatient for this date of service. This code was billed with an inappropriate place of service (22, outpatient hospital).  Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76705 provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet, 2.5 mg.  You asked the Plan to pre-approve Eliquis. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 Eliquis tablet, 2.5 mg.   Benefits for Eliquis 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay and additional amount for the inpatient hospital care provided from February 24, 2020, to March 3, 2020.  You asked the Plan to pay and additional amount for the inpatient care. You say that the secondary diagnosis is supported. The Plan denied your request. The Plan says the provided documentation does not support the billing of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code J96.91, respiratory failure, unspecified with hypoxia, as the secondary diagnosis.  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 J96.91, respiratory failure, unspecified with hypoxia. 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 and additional amount for the inpatient care. Our physician reviewer found even though respiratory failure is documented on discharge summary, supporting medical record documentation was not found within the record. The reviewer found that there were not arterial blood gasses (ABG) or venous blood gas (VBG) results documented. The reviewer found that the enrollee was discharged with pulse oximetry of 99% on a 3-liter nasal cannula. There was no clinical or laboratory evidence of respiratory failure with hypoxia. Therefore, the reviewer has determined that the record did not support the billing of secondary diagnosis code J96.91, respiratory failure, unspecified with hypoxia.   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 and additional amount for the inpatient hospital care provided from February 24, 2020, to March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services on June 18, 2021.  You asked the Plan to pay for the dental services. You say that you were only told that there was no network requirement. The Plan denied your request. The Plan says the services received exceed your benefit limit.  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. The Plan covers up to $1,000 for dental services. Any amount over the $1,000 is the enrollee's responsibility. The documentation shows that the Plan is paying the maximum amount of $1,000 for the dental services received on June 18, 2021. This means you are responsible for any amount over the $1,000. Therefore, we decided that the Plan does not have to pay for the dental services on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services received by an out-of-network provider on June 17, 2021.  You asked the Plan to pay for the dental services received by an out-of-network provider. You say that you feel the Plan should pay for these services. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  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 the dental services received by an out-of-network provider on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve consultation visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visits. You say that this doctor has always treated issues with your legs. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.  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 consultation visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical assistant services provided for an intercostal nerve block provided on May 2, 2021, billed with code 64421.  You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your request. The Plan says code 64421 is not payable for surgical assistant services.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 64421. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services as billed have not been met.  Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided for an intercostal nerve block provided on May 2, 2021, billed with code 64421.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 additional physical therapy visits (97139).  You asked the Plan to pre-approve 2 additional physical therapy visits. You say that the enrollee would benefit from continuing therapy. The Plan denied your request. The Plan says upon completion of the additional 3 visits that are approved at this time, the enrollee will no longer meet medical necessity criteria for continuation of outpatient physical therapy services. 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 2 additional physical therapy visits. 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 in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy visits (97139).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and related services received on June 24, 2021 to July 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and related services. You say that you were told by the provider that they took your Plan. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 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 office visit and related services received on June 24, 2021 to July 2, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services (97110 and 97116) provided on June 5, 2021.  You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not support that a physical therapist was present.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant shall not be billed as services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the record does not indicate that the physical therapist was present in the home when these services were rendered.  Therefore, we decided that the Plan does not have to pay for the physical therapy services (97110 and 97116) provided on June 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve core buildup for tooth #30.  You asked the Plan to pre-approve core buildup. You say that a clinical exam revealed an extensive occlusal surface fracture and recurrent decay. You say that the only treatment option was a full coverage porcelain crown with buildup. The Plan denied your request. The Plan says the core buildup is not needed to retain 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. The Plan covers core buildup when the services are medically necessary and reasonable.      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 core buildup. Our physician reviewer found that it has not been demonstrated that there is insufficient remaining structure to replace the crown on #30 that requires core buildup. Our reviewer says that without additional information showing a loss of supporting structure, there would be no necessity for a core buildup.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of core buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildup for tooth #30.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81479, 81302, 81408, 81330, 81407, 81406, and 81345 provided on December 7, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT codes 81479, 81302, 81408, 81330, 81407, 81406, and 81345 are not supported in the medical record. Specifically, when testing is not currently satisfactorily described by any existing CPT code, the providers should use one unit of code 81479.    Review of the file shows that the services rendered were billed individually and that only one code was not used for the entire bundled multi-test panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.   Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479, 81302, 81408, 81330, 81407, 81406, and 81345 provided on December 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Synvisc-One.  You asked the Plan to pre-approve Synvisc-One. You say that the enrollee has tried conservative treatment, cortisone, Voltaren, Aleve, and topical cannabidiol. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because there are no physical therapy notes showing failed physical therapy.  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 Synvisc-One. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Synvisc. Our physician reviewer found all conservative measures have not been attempted. There is no documentation of physical therapy. Therefore, this is not medically necessary.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc-One.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ambulance transports provided from January 14, 2020, to January 18, 2020.  You asked the Plan to waive the copayments for the ambulance transports. You say that these claims have been denied in error.  You said that these were round-trip transports and should be paid accordingly. The Plan denied your request. The Plan says these services were not denied.  Rather, the allowed amount for each transport ($195.72) is less than the member's cost sharing obligation, so the member is responsible for the full allowed amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $270 copayment per date of service for ambulance services.   The enrollee has been asked to pay a $270 copayment per date of service for the ambulance transports. That is why the Plan has not paid anything on these claims. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for ambulance transports provided from January 14, 2020, to January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided to the enrollee on June 2, 2021.  You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says there is no documented results of a prior prostate biopsy.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent testing on June 2, 2021 because of an elevated prostate specific antigen. The provided record does not indicate that a prior biopsy has been performed. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided to the enrollee on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 4, 2020.   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 Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease  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 provided records did not sufficiently support this type of testing for this enrollee. Genetic testing is not currently considered a testing method that leads to improved outcomes over standard testing and treatment options based on current evidence for patients in the clinical situation as this patient with mixed hyperlipidemia. Therefore, the enrollee does not meet the criteria for the CORUS CAD Panel testing.  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 laboratory services provided to the enrollee on June 4, 2020.