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

We decided that the Plan does not have to pre-approve Arthrodesis, Sacroiliac Joint, Percutaneous or
Minimally Invasive (indirect Visualization), with Image Guidance, Includes Obtaining Bone Graft when
Performed, and Placement of Transfixing Device (27279) and Arthrodesis, Sacroiliac Joint (including
Obtaining Graft) for the diagnosis of Sacroiliitis (27280).
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 requested service is only supported when you have had x-rays
or advanced imaging, a detailed picture study within the last 6 months that shows that you have a problem in
your sacroiliac joint.
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. There is no evidence of sacroiliac joint instability, fracture, or lesion. Sacroiliac joint fusion for
degenerative back pain is experimental. Our physician reviewer found that your 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 Arthrodesis, Sacroiliac Joint, Percutaneous or Minimally Invasive (indirect Visualization),
with Image Guidance, Includes Obtaining Bone Graft when Performed, and Placement of Transfixing Device
(27279) and Arthrodesis, Sacroiliac Joint (including Obtaining Graft) for the diagnosis of Sacroiliitis (27280).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy provided from March 23, 2021, to April
1, 2021, by an OON provider.
You asked the Plan to pay for the speech therapy. You say that the services were medically necessary. You say
at the time of service the enrollee was believed to be covered by traditional Medicare. 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the speech therapy provided from March 23, 2021, to April 1,
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of cranial tongs (20660) provided by an
assistant surgeon on May 24, 2021.
You asked the Plan to pay for the application of cranial tongs (20660). The Plan denied your request. The Plan
says procedures with a status indicator of "1" are not eligible for assistant at surgery reimbursement.
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 20660. 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 application of cranial tongs
(20660) have not been met. Therefore, we decided that the Plan does not have to pay for the application of
cranial tongs (20660) provided by an assistant surgeon on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an opt-out provider on August
30, 2021.
You asked the Plan to pay for dental services. You say that you would like the Plan to reimburse you. The Plan
denied your request. The Plan says the rendering provider is an opt-out Medicare provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. This provider has opted out until March 25, 2023.
Therefore, we decided that the Plan does not have to pay for dental services provided by an opt-out provider
on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 6, 2021, and September 13,
2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate
claim.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one
previously processed and paid by the Plan. Duplicate claims are not payable. 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 provided on August 6, 2021, and September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
January 15, 2021, to January 19, 2021.
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 the DRG was updated.
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.
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
services at issue in this case were not supported by the medical records. Our physician reviewer found the
review indicates that the correct DRG and diagnosis codes were not used in this case. The documentation was
incomplete to reflect evidence of abnormal arterial blood gas results consistent with acute respiratory failure,
need for high flow supplemental oxygen or invasive/noninvasive ventilatory assistance during the encounter.
The documentation indicated the patient's ability to actively participate in speech, physical and occupational
therapy sessions throughout the encounter and resource intense interventions or monitoring consistent with an
acute life-threatening deterioration and subsequent failure of the respiratory system was not located in the
record received. In this case, the documentation received was incomplete to substantiate the condition of acute
respiratory failure 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
for inpatient hospital services provided to the enrollee from January 15, 2021, to January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network services you received on October 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit was
exhausted.
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 there is a POS plan
coverage limit of $3,000 per calendar year. Once this limit is reached, you are responsible for 100% of the cost
of out-of-network services.
Review of the file shows that you were provided out-of-network services on October 6, 2021. The Plan will
pay a maximum of $3,000 per calendar year for covered out-of-network services. The records show that the
$3,000 benefit limit was already reached prior to the services in question. You are responsible for 100% of the
cost of these out-of-network services.
This means that you have been asked to pay the correct amount based on your contract with the Plan.
Therefore, we decided that the Plan does not have to pay for the out-of-network services you received on
October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a
total knee arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan
says there is no documentation provided to support the expectation the enrollee will require a greater than 2
midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee is scheduled/approved for a total knee arthroplasty. The record
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or
more midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tezspire.
You asked the Plan to pre-approve Tezspire. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria.
The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Tezspire. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 64-
year-old female with severe persistent asthma with evidence of elevated Immunoglobulin E on laboratory
testing. The Plan requires a trial of Xolair before they will approve the requested drug, Tezspire. In this case,
the patient has not tried and failed the required drug. Based on the medical records provided there is no
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the
patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tezspire have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tezspire.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management provided on March 30, 2021.

You asked the Plan to pay for observation care discharge day management. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for observation care discharge day management provided on March 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304).
You asked the Plan to pre-approve Zilretta. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been
met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
Plan requires a trial of drugs Dexamethasone and Triamcinolone before they will approve the requested drug.
The case record does not contain documentation of trial and failure of Dexamethasone and Triamcinolone. The
documentation does not support that Dexamethasone and Triamcinolone would likely be less effective and/or
would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve treatment with Zilretta (J3304).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete
series of radiographic images (D0210) provided by a participating provider on September 30, 2021.
You asked the Plan to pay for a comprehensive oral evaluation and a complete series of radiographic images.
You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit
limit for D0150 and D0210 has already 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. The Plan covers a
comprehensive oral evaluation once every three years and a complete series of radiographic images once every
five years.
We looked the file and Medicare rules. D0150 and D0210 was provided on Jul y 27, 2020. Based on this
information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and a complete
series of radiographic images have already been met. Therefore, we decided that the Plan does not have to pay
for a comprehensive oral evaluation (D0150), and a complete series of radiographic images (D0210) provided
by a participating provider on September 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).

You asked the Plan to pre-approve Entyvio. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 59-year-old male with Crohn's disease who reportedly has failed treatment with tumor necrosis factor inhibitors Humira and Remicade. The Plan requires a trial of Stelara before they will approve the requested drug, Entyvio. In this case, the patient has not tried and failed the required drug. In addition, based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (81455) provided on April 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.
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 that genetic testing procedures submitted with code 81455 are unlikely to impact
therapeutic decision-making in the clinical management of the patient, and therefore are not considered
medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (81455) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network telehealth services provided on
September 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
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 out-of-
network telehealth services are not covered.
Review of the file shows that out-of-network telehealth services were provided to the enrollee on September
20, 2021. These services are not covered by the Plan. The Plan only covers in-network telehealth services
Therefore, we decided that the Plan does not have to pay for the out-of-network telehealth services provided on
September 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on June 26, 2021.
You asked the Plan to pay for ambulance services. You say that the ambulance transport was before the patient
enrollee into hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition. The
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers
attending physician services and all care unrelated to the terminal illness until the first day of the month
following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for ambulance services provided on June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150), intraoral - complete series of radiographic images (D0210), and prophylaxis - adult (D1110)
provided July 1, 2021.
You asked the Plan to pay for the comprehensive oral exam, complete series of intraoral x-rays and dental
cleaning. You say that the provider is opted out of Medicare because Medicare doesn't typically cover dental
services, but you feel the Plan should cover the services. The Plan denied your request. The Plan says these
services are not covered because the provider has opted out of Medicare.
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 the
comprehensive oral exam, complete series of intraoral x-rays and dental cleaning when the services are
provided by a dentist who has not opted out of Medicare.
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent,
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information,
we decided that the Plan's rules for coverage of the comprehensive oral exam, complete series of intraoral x-
rays and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation - new or established patient (D0150), intraoral - complete series of radiographic
images (D0210), and prophylaxis - adult (D1110) provided July 1, 2021.