Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of a benign lesion (D7410) provided by a 
participating provider on January 11, 2021. 
 
You asked the Plan to pay for an excision of a benign lesion. You say that you were assisted in enrolling in a 
dental plan. You say that you were not enrolled into the correct plan. The Plan denied your request. The Plan 
says the enrollee's dental coverage limit of $250 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. 

We looked at the file and Medicare rules. The total amount you are being asked to pay is $2,090. The record 
shows that you have exhausted the Plan benefit limit of $250 for non-Medicare-covered dental services on 
January 8, 2021. Based on this information, we decided that the Plan's rules for coverage of an excision of a 
benign lesion have not been met. Therefore, we decided that the Plan does not have to pay for an excision of a 
benign lesion (D7410) provided by a participating provider on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation 
services (A0427, A0425) provided on May 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel these services 
would not have been necessary if the enrollee's physician had not recently changed/discontinued their 
medication. The Plan denied your request. The Plan says documentation shows that the enrollee was provided 
with ambulance transportation on the date in question. Ambulance services require a $275 copayment per trip. 
 
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 $275 copayment for each one-way ambulance trip. 

The enrollee has been asked to pay a $275 copayment for the ambulance services. 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 copayment for the emergency ambulance transportation services (A0427, A0425) provided 
on May 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan intra-articular injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found there is no imaging 
documented, and the results of the Zilretta injection are not documented. The request does not meet the 
requirements and is therefore considered 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan intra-articular injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided 
December 17, 2020. 
 
You asked the Plan to pay for the duplex scan. You say that please review the attached requested medical 
records. After a careful audit of your claim, you feel that you have not been reimbursed fairly and you request 
the Plan to reconsider for additional reimbursement. The Plan denied your request. The Plan says the records 
do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 93880 is duplex scan of extracranial arteries, complete 
bilateral study. 
 
We find that CPT code 93880 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of duplex scan of extracranial arteries, complete bilateral study. Also, there is a 
more appropriate code for the service provided (93975). The Plan made multiple attempts to contact the 
provider for additional information. Based on this information, we decided that Medicare rules for coverage of 
the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex 
scan of extracranial arteries (93880) provided December 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services.. You say that the services are 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 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily basis.  
 
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 skilled nursing facility services. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are no longer having consistent, meaningful functional benefit from daily skilled therapies, and appears to have reached a new functional baseline.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for St. John's Wort Extract purchased on July 16, 2021.

You asked the Plan to pay for St. John's Wort Extract. You say that you are resubmitting the claim under perks
rewards. You say that this is part of your medication that was paid before. The Plan denied your request. The
Plan says St. John's Wort is not an eligible expense.

The Plan has a Pick Your Perks program that reimburses you for eligible services and items. The St. John's
Wort Extract is not an eligible item. Therefore, we decided that the Plan does not have to pay for St. John's
Wort Extract purchased on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 7, 2020.

You asked the Plan to pay for lab tests. You say that the Plan is required to pay for this testing in full. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
submitted does not support the Place of Service (POS) code billed on this claim.

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 documentation submitted shows that the sample for this testing
was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on
August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 orthopedic footwear.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90791 and 90837) provided on
February 3, 2021, through February 24, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says telehealth services are only covered
when rendered in-network.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if
regular Medicare would pay for it in this case.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have not been met. Specifically, the record indicates that this was a
telehealth service that was rendered out-of-network. The Plan only covers these services when provided in-network.
Additionally, the claim does not include a referring provider to determine if the member was referred
for this service by an in-network provider. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (90791 and 90837) provided on February 3, 2021, through February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 

You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 

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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Keytruda is medically reasonable and necessary for the enrollee. The documentation does not support that the Keytruda is safe and effective for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
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.

You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a lower level of care.

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. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation.

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure does not have enough evidence that consistently shows proof of benefit.

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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered experimental and investigational in nature. The requested block is not reasonable or 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON physical therapy services. You say that the requested OON provider is the best for treatment of balance and inner ear coordination, which is what is at the root of your concerns. The Plan denied your request. The Plan says the treatment required can be provided within the Plan's network.

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 physical therapy services 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 pre-approve routine transportation services to your primary care
physician's (PCP's) office.

You asked the Plan to pre-approve the routine transportation services to your PCP's office. You say that the
rides being requested are very important because you are having lots of difficult health problems right now and
need to make sure you see your PCP. You say that these appointments to see your PCP could keep you out of
the hospital. The Plan denied your request. The Plan says the routine transportation trips you are requesting
exceed the benefit allowance for mileage.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation services with a 30-mile limit per trip.

We looked at your request, the records in the case file, and the rules. The case file shows that the address for
your PCP's office is more than 30 miles from your home address. Based on this information, we decided that
the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan
does not have to pre-approve routine transportation services to your primary care physician's (PCP's) office.
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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 21, 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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 21, 2021.