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

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your
request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is
not medically necessary. Our physician reviewer found the review has determined that the requested use of
Prolia is not FDA-approved for the enrollee's diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued out of network referral for chiropractic
services for the enrollee.
You asked the Plan to pre-approve the continued referral. You say that this is medically necessary. The Plan
denied your request. The Plan says there are in-network chiropractors available.
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
a continued out of network referral for chiropractic services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203) to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you are not satisfied with the care you received
from an in-network provider. The Plan denied your request. The Plan says there are multiple in-network
providers that would be able to provide medical you need.
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 an office visit (99203) 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 a medical eye exam (92014) and an ultrasound echography exam of the eye (76519) provided on May 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an eye exam and an ultrasound of the eye. You say that the enrollee initially presented a card with a different insurance company, and the claim was denied. You also say the claim was billed to the correct Plan and denied for no authorization. You would like to request a retro-authorization and have the Plan re-process the claim for payment. The Plan denied your request.  The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.  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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a medical eye exam (92014) and an ultrasound echography exam of the eye (76519) provided on May 12, 2021, 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 StretchMed service.  You asked the Plan to pay for the StretchMed service. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only with a $250 allowance towards the cost of a membership for a qualified health club or fitness facility.  The Plan's rules for coverage of gym benefits have not been met because StretchMed is not a qualified health club or fitness center. Therefore, we decided that the Plan does not have to pay for the StretchMed service.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on May 8, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on May 8, 2021, 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 retainer crown (D6740) provided on May 6, 2021.  You asked the Plan to pay for the dental service. You say that you went to the dentist to get your bridge adjusted. You say that you were told that you were not charged for this. You say that you asked them not to use all of your money. You also say that you should not have to pay this bill. The Plan denied your request. The Plan says there is an annual allowance of $4,500 for covered dental services. The Plan also says that allowance has been exhausted.  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 annual allowance of $4,500 has been exhausted.   Date of Service Billed Amount Plan Paid Your Responsibility 3/8/2021 $95 $60 $0 3/24/2021 $265 $117 $0 4/20/2021 $1,385 $1,075 $0 4/27/2021 $155 $105 $0 5/6/2021 $4,800 $3,178 $451 TOTAL:  $4,500   Additionally, the file specifically states you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6740) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayments for the specialist office visits provided from July 16, 2020, to November 23, 2020.  You asked the Plan to waive the copayments for the specialist office visits. You say that the provider is a nurse, and you want the bill updated to reflect the primary care physician. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $40 copayment for visits to specialists.   The Plan says you must pay a $40 copayment for each of the specialist office visits. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for each the specialist office visits. The record does not show the specialty of the Advanced Practice Registered Nurse. Therefore, we decided that the Plan has to waive the copayments for the specialist office visits provided from July 16, 2020, to November 23, 2020.   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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics provided on September 1, 2021.  You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FoundationOne Heme testing.  You asked the Plan to pay for the FoundationOne Heme testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this testing is considered experimental.  The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 FoundationOne Heme testing. Our reviewer says that the documentation submitted does not include and clinical notes. Our physician reviewer found there is insufficient information to determine if Medicare criteria have been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FoundationOne Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation from February 4, 2022, forward.  You asked the Plan to pre-approve inpatient substance abuse rehabilitation from February 4, 2022, forward. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that in order for an inpatient hospital stay for alcohol rehabilitation to be covered under Medicare it must be medically necessary for the care to be provided in the inpatient hospital setting rather than in a less costly facility or on an outpatient basis.   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 inpatient substance abuse rehabilitation from February 4, 2022, forward. Our reviewer says that based upon the records provided you do not meet criteria for inpatient substance abuse rehabilitation from February 4, 2022, forward. Our physician reviewer found you are not a danger to yourself or others, do not have auditory or visual hallucinations and are cooperative with treatment. You are not showing any acute signs of withdrawal. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient substance abuse rehabilitation from February 4, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation from February 4, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September 9, 2021.  You asked the Plan to waive the copayment for the surgery. You say that you were not aware that this service would be charged as an outpatient hospital. The Plan denied your request. The Plan says the proper copayment 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 $250 copayment for Medicare-covered surgery or other services at an outpatient hospital.     You have been asked to pay a $250 copayment for surgery. surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgent care services provided on September 29, 2021.  You asked the Plan to waive the copayment for the urgent care services. You say that the provider told you there would be no copayment The Plan denied your request. The Plan says the proper copayment for this service 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 $40 copayment for Tier 2 Medicare-covered urgently-needed-services.     You have been asked to pay a $40 copayment for urgent care services. Urgent care services falls within the Urgently needed 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 urgent care services provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on September 22, 2020.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 11 for an office setting, but the record shows that the sample was taken in a nursing facility. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered 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 pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of facet joint.  You asked the Plan to pre-approve RFA services. You say that this is medically necessary for your condition. 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 an initial thermal RFA is covered when 2 MBBs have been performed.   We looked at the file and Medicare rules. In this case, you have only received one set of diagnostic MBBs, not two. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of facet joint.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on July 14, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 14, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on September 14, 2021.  You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on September 14, 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 for the enrollee.  

You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical and occupational therapy and can tolerate 3 hours of therapy. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.  

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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for elective hip replacement surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.