Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (DME) (E1399) provided on April 18, 2021 to April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says you did not obtain prior authorization for use of an out of network provider.

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 durable medical equipment (DME) (E1399) provided on April 18, 2021 to April 21, 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 an endodontic therapy (D3310).

You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service is not covered.

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 an endodontic therapy (D3310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 21, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from November 21, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from November 21, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 21, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 21, 2021, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 21, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 21, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on February 19, 2021, through February 25, 2021 and billed at the 872 Diagnosis Related Group (DRG) rate.

You asked the Plan to pay for the inpatient hospital services billed at the DRG 872 rate. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not support diagnosis code A41.9 for Sepsis.

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. In this case, you billed the inpatient services provided with diagnosis code A41.9. 

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 inpatient hospital services billed at the DRG 872 rate. Our reviewer says that the documentation did not support diagnosis code A41.9 for Sepsis, unspecified organism. Our physician reviewer found the emergency department note states that criteria for systemic inflammatory response syndrome/Organ dysfunction was met but infection is not suspected. The member was not diagnosed with severe sepsis. 

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 on February 19, 2021, through February 25, 2021 and billed at the 872 Diagnosis Related Group (DRG) rate.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the angiography (75716) provided on April 5, 2021.  You asked the Plan to pay for the angiography. You say that you would like reconsideration because it would be appropriate to bill for the 75716-59 along with the intervention 37227 because the member had intervention back in 2018/2019 and the member is complaining of worsening severe bilateral leg pain and foot pain with numbness and tingling. The Plan denied your request. The Plan says CPT code 75716 is included in CPT code 37227.  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 75716 is angiography, extremity, bilateral, radiological supervision and interpretation   We asked our coder 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 angiography. Our reviewer says that CPT code 75716 does not meet criteria for billing or reimbursement consideration. Our reviewer found an angiography would be needed to perform the primary procedure rendered on this date of service, therefore, CPT 75716 would not be reported separately, unless was a separate identifiable service. The documentation does not support CPT 75716 as separate procedure.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the angiography have not been met. Therefore, we decided that the Plan does not have to pay for the angiography (75716) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture (D5213).  You asked the Plan to pre-approve a partial upper denture. You say that you understand that this service is not covered by your plan. You say that your plan would cover a bridge. You also say that you do not have a tooth for it to bond to. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.  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 partial upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper left quadrant.  You asked the Plan to pre-approve periodontal scaling and root planing. You say that you want the denial reviewed for approval. The Plan denied your request. The Plan says the upper left quadrant does not have enough teeth that currently meet a medical need.    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 periodontal scaling and root planing when the services are medically necessary and reasonable.   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 periodontal scaling and root planing. Our reviewer says that scaling and root planing in the upper left quadrant does not meet the criteria for coverage. Our physician reviewer found that the code requested is for four or more teeth per quadrant and only three teeth are present in the quadrant.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper left quadrant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Doxorubicin, Cyclophosphamide, Dexamethasone, Palonosetron, Cinvanti, and Neulasta.

You asked the Plan to pre-approve the drug regimen. The Plan denied your request. The Plan says the drug regimen is not being prescribed for a medically accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the drug regimen. Our physician reviewer found that in this case, the enrollee has a diagnosis of ER negative, PR positive, Her2 negative locally advanced breast cancer. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Doxorubicin, Cyclophosphamide, Dexamethasone, Palonosetron, Cinvanti, and Neulasta.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (Corus CAD Assay) provided to the enrollee on June 23, 2020.   You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says there is no demonstration that this testing results in improved patient outcomes, or that this testing changes physician management to result in improved patient outcomes.  The Plan must follow Medicare rules. Medicare rules say that there is no evidence that use of test results from the Corus CAD Assay result in improve patient outcomes.  This testing is not considered to be beneficial at this time. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (Corus CAD Assay) provided to the enrollee on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric bed (E0265).  You asked the Plan to pre-approve a total electric bed. You say that the enrollee requires a fully electric hospital bed, manual or semi-electric is not an acceptable alternative. The Plan denied your request. The Plan says the Plan does not cover fully electric hospital beds.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric bed (E0265).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on August 2, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you do not think you should have to pay this copayment. You said that you left prior to seeing a doctor because the wait was too long, and your symptoms had subsided. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for these services ($77.70) is less than your copayment obligation, you are responsible for the full allowed 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 per visit for emergency care.   You have been asked to pay a $90 copayment per visit for the ER visit. This copayment applies each time you visit the ER, regardless of the extent of services you receive. 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 emergency room (ER) visit you had on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator and supplies and knee brace provided to the enrollee on June 10, 2021.  You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet medical necessity criteria for these items.  The Plan must follow Medicare rules. Medicare rules say that a TENS is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain and that knee orthoses are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).  We looked at the file and Medicare rules. The file indicates that the TENS was not requested for chronic, intractable pain or acute post-operative pain and that there is no recent injury to or a surgical procedure on the enrollee's knee. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator and supplies and knee brace provided to the enrollee on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular risk assessment screening provided on September 8, 2020.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment screening provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not meet the criteria for the step therapy exception.  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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.   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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377).  You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options with their own switches.  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 an expandable controller. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the records document that the enrollee has 3/5 bilateral upper extremity strength and is independent with feeding, indicating she has adequate upper extremity strength and function to control the wheelchair's power options with their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on April 5, 2021.  You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you have seen the same doctor at other locations and only paid $20. The Plan denied your request. The Plan says you were charged this copayment correctly.  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 $100 copayment for surgery or other services at an outpatient hospital facility.   You have been asked to pay a $100 copayment for the arthrocentesis procedure. The facility where you received this service is considered an outpatient hospital facility.   That is why the arthrocentesis procedure falls within the surgery or other services at an outpatient hospital facility 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 arthrocentesis procedure you had at an outpatient hospital facility on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for all four quadrants.  You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are medically necessary The Plan denied your request. The Plan says the x-rays provided show normal bone levels with no bone loss and no calculus buildup on the tooth roots. There is insufficient evidence to indicate the requested deep cleaning services are medically necessary.  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 periodontal scaling and root planing when the services are medically necessary and reasonable.   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 periodontal scaling and root planing. Our reviewer says that the requested periodontal scaling and root planing services are not medically necessary.   Our physician reviewer found that the included periodontal charting shows pockets in excess of 3mm in all four quadrants, with a maximum recorded pocket depth of 7 mm along with several 4, 5 and 6mm readings in all quadrants. The supplied full series of x-rays do not show any significant bone loss and no calculus on the root surfaces. The pocket measurements may have been as a result of gingival inflammation which is a product of gingivitis, and not periodontal disease which affects the attachment and supporting bone. The Policy provides that the criteria for periodontal scaling requires, "a minimum of four (4) teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths in multiple sites. Additionally, at least one of the following must be present: 1) Radiographic evidence of root surface calculus (cementum). 2) Radiographic evidence of noticeable loss of bone support."  Given the lack of calculus on the root surfaces and no notable loss of bone support in any of the four quadrants, the request for scaling and root planing would not be considered medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for all four quadrants.