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

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
You asked the Plan to pre-approve Genvisc 850. You say that this is medically necessary for the enrollee's osteoarthritis and pain in right knee. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, Orthovisc.
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 Genvisc 850. Our reviewer says that the
request for Genvisc 850 is not medically necessary. Our physician reviewer found the provided documentation
indicates that the enrollee has tried Monovisc. The reviewer found that the documentation does not indicate the
enrollee has tried and failed Orthovisc. The reviewer found that the provided documentation does not indicate
that Orthovisc would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the
reviewer found that the step therapy criteria has not 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 Genvisc 850 have not been met. Specifically, the file shows that the ernollee
has not tried and failed the required drug, Orthovisc. Therefore, we decided that the Plan does not have to preapprove
Genvisc 850 (J7320).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that the patient requires additional home
health services. The Plan denied your request. The Plan says additional home health services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our reviewer
says that the requested home health visits are not medically necessary for this patient. Our physician reviewer
found the enrollee does not have documented, ongoing home health physical therapy needs. The enrollee is
functioning at a level commiserate with a lower level of care (i.e., home exercise plan or outpatient
therapy). As such, the requested ongoing home health services are not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra.
You asked the Plan to pre-approve Actemra. You say that evidence supports starting the enrollee on Actemra. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Actemra should not be administered in combination with another drug such as Stelara due to the risk of side effects.
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 Actemra. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Actemra. Our physician reviewer found the Food & Drug Administration (FDA) has not stated that the requested formulation of Actemra is indicated for the enrollee's diagnosis of Giant Cell Arteritis. The requested use of Actemra is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Actemra.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on July 16, 2021.
You asked the Plan to pay for the computed tomography (CT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 for the computed tomography (CT) 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) coded 70450 provided on July 16, 2021
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 that have not been denied. The record does not indicate that the enrollee requires services she is not currently receiving but that would be available at the LTACH. 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: 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 LTACH is the most appropriate setting for the enrollee to receive ongoing care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that are not available at the health care setting being offered by the Plan. 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: 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 continued SNF services. You say that this is affecting both your physical improvement but also your mental health. You stated that you want to regain your independence. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.
The Plan says that while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.
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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing service needs or skilled therapy service needs. The doctor found that you do not require skilled nursing or therapy services on a daily basis. The doctor also found that you do 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 continued 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99291 provided on June 11, 2021.
You asked the Plan to pay for procedure code 99291. You say that code 99291 is a standalone code The Plan denied your request. The Plan says this code is not separately payable without a 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 procedure code 99291 is a column II code to column I code 99152.
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 procedure code 99291 provided on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve local anesthesia in conjunction with operative or surgical procedures (D9215).
You asked the Plan to pre-approve the local anesthesia. You say that tooth #15 has a large recurrent decal on the distal facial. The Plan denied your request. The Plan says this service is not covered under the enrollee's plan.
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 pre-approve local anesthesia in conjunction with operative or surgical procedures (D9215).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the podiatry visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the podiatry visit. You say that you want to see the provider that is closer to your job site to address your toenail issue. The Plan denied your request. The Plan says the provider is out-of-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 the podiatry visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided by May 6, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had no choice going to see this doctor. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment.
You have been asked to pay a $10 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the specialist office visit provided by May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the freestyle libre 14-day sensor.
You asked the Plan to pre-approve freestyle libre 14-day sensor. You say that the item is medically necessary.
The Plan denied your request. The Plan says you are not using insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of freestyle
libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the
freestyle libre 14-day sensor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the raised toilet seat (E0244), commode chair (E0168), wheelchair (E1039), and shower bench(E1399), provided on June 11, 2021 to June 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the raised toilet seat, commode chair, wheelchair and shower bench. You say that the items are medically necessary. The Plan denied your request. The Plan says in-network providers must be used for the purchase of durable medical equipment and the raised toilet seat and shower bench are not primarily medical in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the raised toilet seat (E0244), commode chair (E0168), wheelchair (E1039), and shower bench(E1399), provided on June 11, 2021 to June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4).
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 pre-approve four gingival irrigations (D4921 x4).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you are an independent laboratory and do not receive patient information until after services are rendered. You say it is impossible to obtain prior authorization. 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 record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on May 10, 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 magnetic resonance angiography services coded as 70544 and provided on July 16, 2021.
You asked the Plan to pay for the magnetic resonance angiography 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 has not been billed with an appropriate modifier as required by Medicare rules.
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 the magnetic resonance angiography services is a column II code to column I code 70553. 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 magnetic resonance angiography services coded as 70544 and provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve a complete upper denture. We decided that the Plan does not have to pre-approve a partial lower denture.
You asked the Plan to pre-approve a complete upper denture and a lower partial denture. You say that you did not receive any dentures. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
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 decided that the Plan has to pre-approve a complete upper denture.
The Evidence of Coverage clearly states that complete upper denture is covered once every 5 plan years. The
record shows that the frequency limit has not been reached as the Plan did not pay for the complete upper
denture that the enrollee received on October 26, 2017. Therefore, we decided that the Plan has to pre-approve
a complete upper denture.
We also decided that the Plan does not have to pre-approve a partial lower denture.
Though the Plan offers a dental benefit in excess of Medicare coverage and denture are listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for a partial lower denture that you
received on November 20, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial
lower denture.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture to be provided by an out-of-network dentist.
You asked the Plan to pre-approve the complete upper denture. You say that you have been trying to get dentures since August, but the original dentist was denied for being out-of-network. You say that you are allowed a full set of dentures every five years, so you don't know what the problem is. The Plan denied your request. The Plan says in-network providers are available.
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, out-of-network dental services are not among those covered under this benefit. Contact the Plan in regard to receiving the denture from an in- network provider. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture to be provided by an out-of-network dentist.