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

We decided that the Plan does not have to pre-approve Ozempic.
You asked the Plan to pre-approve Ozempic. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Ozempic.
Benefits for Ozempic 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed injection of intra-articular steroids.
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. Our reviewer says that the requested Synvisc is not medically necessary. Our physician reviewer found this enrollee is being treated for primary osteoarthritis. He presented with pain in the bilateral knees that is greater on the right and rated at 4. The pain is aching, sharp, burning, electrical, stiffness, and is persistent/constant. Exam reveals bilateral knee tenderness. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures including an intra-articular cortisone injection. There is documentation of an elevated HgA1c noted as "pre-diabetic"; however, there is no documentation of any treatments being provided or indication of a treatment plan for the increased level. In addition, the x-rays provided indicate early arthritic changes are seen in the knees bilaterally with very mild medial compartment joint space narrowing and tiny osteophytes on both sides. Advanced knee osteoarthritis is not demonstrated. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Synvisc is not 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global
surgical package.
We looked at the file and Medicare rules. The file shows that procedure code 99291 (critical care services) was
billed on the same day as minor surgical procedure 12013 (repair of wound (2.6 to 5.0 centimeters) of the face,
ears, eyelids, nose, lips, and/or mucous membranes). Payment for these services is included in the global
surgical package. Therefore, we decided that the Plan does not have to pay for the critical care services
rendered on February 8, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care and treated for worsening memory loss with inability to provide self-care. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a supervision to independent level with functional mobility including gait to 200 feet. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care, an inpatient hospital stay,
and a SNF stay provided from February 26, 2021, to March 21, 2021.
You asked the Plan to waive the copayments for emergency care, an inpatient hospital stay and a SNF stay.
You say that you feel that you should owe one less day for an inpatient hospital stay because you owe an
emergency room copayment for February 26, 2021. You state that you were discharged on March 3, 2021, not March 4, 2021. The Plan denied your request. The
Plan says the claims were processed correctly and you are being charged the correct 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). Your contract with the Plan clearly says that you must pay a $90
copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $250
copayment for days 1-7 for inpatient hospital care. Your contract with the Plan also clearly says that you must
pay a $0 copayment for days 1-20 and a $184 copayment for days 21-100 for SNF care
The record shows that you received emergency care on February 26, 2021. Therefore, you are responsible to
pay the $90 copayment.
The medical records show that you had an inpatient hospital stay from February 26, 2021, to March 4, 2021.
Therefore, you are responsible to pay a $250 copayment for days 1-5 (February 26, 2021, To March 3, 2021).
$250 (copayment) x 5 (inpatient days) = $1,250.
The total amount you owe is: $1,340.
The medical records show that you had a SNF stay from March 4, 2021, to March 21, 2021. You are not being
charged a copayment for this stay.
You have been asked to pay the total copayment amount of $1,340 for emergency care and an inpatient hospital
stay. Emergency care falls within emergency care benefit category. An inpatient hospital stay falls within the
inpatient hospital care benefit category. SNF care falls within the SNF care 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 copayments for emergency care, an inpatient hospital stay, and a SNF stay provided
from February 26, 2021, to March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found a home ventilator is considered not medically necessary for this enrollee. The enrollee has severe chronic obstructive pulmonary disease (COPD) and also requires regular use of opioids for control of chronic pain. CO2 retention was demonstrated on an arterial blood gas done while the enrollee was acutely ill. It is not known whether the enrollee retains CO2 when stable.
BiPAP has not been tried at home. Some BiPAP devices can provide the AVAPS mode of support, and Medicare does not cover a home ventilator when used as BiPAP. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 22, 2021.
You asked the Plan to pay for the comprehensive evaluation. You say that this service was necessary and should be covered as it was provided in-network. The Plan denied your request. The Plan says you previously had a comprehensive oral evaluation in March of 2020, which was paid for by the Plan. The Plan can only cover one comprehensive oral evaluation every three years.
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 can cover one comprehensive oral exam (D0150) every three years. Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive evaluation is requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous comprehensive exam in March 2020, which is less than three years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell stimulation and subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 10, 2020.
You asked the Plan to pay for electrical cell stimulation represented by codes G0283, 99211, 97112, 96372, and 97112, and subcutaneous injection represented by J3490, J3420, J3415, J3411, J1955, and J2001. You say that the services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the clinical value and effectiveness of electrical cell stimulation and the subcutaneous injection in the setting of idiopathic peripheral neuropathy, paresthesia and chronic pain have 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 looked at the file and Medicare rules. There is no history of vitamin deficiency or edema in the medical records. Based on this information, we decided that Medicare rules for coverage of electrical cell stimulation represented by codes G0283, 99211, 97112, 96372, and 97112, and subcutaneous injection represented by J3490, J3420, J3415, J3411, J1955, and J2001. have not been met. Therefore, we decided that the Plan does not have to pay for electrical cell stimulation and subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an oxygen concentrator.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance.
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 referral to an out-of-network provider for an oxygen concentrator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity prosthesis with K2 components (L5972, L5986).
You asked the Plan to pre-approve the lower extremity prosthesis with K2 components. You say that the requested prosthetic components are not medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain components/additions to a prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner. 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 lower extremity prosthesis with K2 components. Our reviewer says that the requested prosthetic is not medically necessary. Our physician reviewer found it is reported that the member was a community ambulator prior to the amputations. However, that was over 2 years ago, and it does not appear that the member has had much therapy since then. Further, it is not clear what the member has done for mobility since the first amputation. The documentation indicates that the member currently does not appear to be a K2 ambulator and these components are only approved for K2 or above ambulators. 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 lower extremity prosthesis with K2 components have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower extremity prosthesis with K2 components (L5972, L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Endoskel Knee-Shin Swing & Stance Phase Control (L5828), a Endoskel Knee-Shin stance flex feature (L5845), a Endoskel Knee-Shin system fluid stance extension (L5848), a lower extremity Knee-Shin Swing & Stance Phase (L5856), a lower extremity multi-axial rotation unit (L5986), a lower extremity fit system (L5987, disartic knee (L5850), and disartic alignable system (L5920).
You asked the Plan to pre-approve a Endoskel Knee-Shin Swing & Stance Phase Control, a Endoskel Knee-Shin stance flex feature, a Endoskel Knee-Shin system fluid stance extension, a lower extremity Knee-Shin Swing & Stance Phase, a lower extremity multi-axial rotation unit, a lower extremity fit system, disartic knee, and disartic alignable system. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a determination of the type of knee for the prosthesis will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the beneficiary. 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 a Endoskel Knee-Shin Swing & Stance Phase Control, a Endoskel Knee-Shin stance flex feature, a Endoskel Knee-Shin system fluid stance extension, a lower extremity Knee-Shin Swing & Stance Phase, a lower extremity multi-axial rotation unit, a lower extremity fit system, disartic knee, and disartic alignable system. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation indicates you use a walker for ambulation which is not consistent with a K3 ambulator therefore this request 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 a Endoskel Knee-Shin Swing & Stance Phase Control, a Endoskel Knee-Shin stance flex feature, a Endoskel Knee-Shin system fluid stance extension, a lower extremity Knee-Shin Swing & Stance Phase, a lower extremity multi-axial rotation unit, a lower extremity fit system, disartic knee, and disartic alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Endoskel Knee-Shin Swing & Stance Phase Control (L5828), a Endoskel Knee-Shin stance flex feature (L5845), a Endoskel Knee-Shin system fluid stance extension (L5848), a lower extremity Knee-Shin Swing & Stance Phase (L5856), a lower extremity multi-axial rotation unit (L5986), a lower extremity fit system (L5987, disartic knee (L5850), and disartic alignable system (L5920).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of impacted teeth (D7241) provided on May 19, 2021.
You asked the Plan to pay for the impacted tooth extractions. You say that you were not told this service would not be covered and would not have had this procedure if you knew you would have to pay out of pocket. The Plan denied your request. The Plan says this service is not covered by your dental benefit. The Plan also reviewed your phone log with customer service and found that both you and the provider were told that this was not a covered service. You were also mailed a notice of denial of medical coverage prior to services.
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 removal of impacted teeth (D7241) provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 22, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on January 22, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for endotracheal intubation (31500-51) provided on February 11, 2021.
You asked the Plan to pay for endotracheal intubation. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an inappropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that Multiple Procedure (Modifier 51) Indicator of 0 indicates that no payment adjustment rules for multiple procedures apply. We looked at the file and Medicare rules. The billed code, 31500, has a Multiple Procedure (Modifier 51) Indicator of 0, but it was billed with modifier 51. It is not appropriate to bill this code with modifier 51. Based on this information, we decided that Medicare rules for coverage of endotracheal intubation have not been met. Therefore, we decided that the Plan does not have to pay for endotracheal intubation (31500-51) provided on February 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2020.
You asked the Plan to pay for the laboratory services. You say that this is a coronavirus related lab test that
must be paid. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 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 the laboratory services provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on April 28, 2021.
You asked the Plan to pay for the comprehensive periodontal exam. You say that this exam was necessary and
should be covered. The Plan denied your request. The Plan says this type of evaluation is not covered by your
dental 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 the
comprehensive periodontal evaluation (D0180) provided on April 28, 2021.