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

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has had good results with this last year
and would like to try it again. The Plan denied your request. The Plan says that the member has not tried and
failed Monovisc.
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 Euflexxa. Our reviewer says that
Euflexxa is not medically reasonable and necessary for the enrollee. The patient has not tried and failed
Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc would likely be
less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer
found that the enrollee's condition does not meet step therapy criteria for Euflexxa.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225) and resin-based composite - two surfaces, anterior (D2331) provided February 15, 2021.
You asked the Plan to pay for the upper partial denture and filling. You say that 2020 was a challenging year and you would like the Plan to cover the dental services. The Plan denied your request. The Plan says these services are not covered under your benefits.
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
maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225) and resin-based composite - two surfaces, anterior (D2331) provided February 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says placement in a skilled nursing facility at this time would seem to be inappropriate.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled needs.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require nursing and/or skilled therapy services on a daily basis. Further services can be provided at a lower level of care. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport provided on September 9, 2019.

You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the date when the services were rendered.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for ambulance service, basic life support, emergency transport was not filed until June 14, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport provided on September 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental healthcare (90792) provided on November 2, 2020.

You asked the Plan to pay for outpatient mental healthcare. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.

We looked at the file and Medicare rules. The only diagnosis code billed, F01.50, is a manifestation code. The etiology code must be billed before this code. Based on this information, we decided that Medicare rules for coverage of outpatient mental healthcare have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental healthcare (90792) provided on November 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The documentation indicates the therapy is now for knee pain for 6 sessions. The documentation does not reveal significant objective functional deficits of the knee or gait that requires 6 formal therapy sessions. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee reports her knees are feeling better since incorporating stretching and strengthening, which she can continue to do independently. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on March 13, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says prior authorization is required for non-emergent ground ambulance services. Prior authorization was not requested nor obtained.
The contract with the Plan says prior authorization is required for non-emergent ground and air ambulance services.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Specifically, prior authorization was not requested nor obtained. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2020.
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 laboratory services rendered on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a commode chair (E0163), bathtub rails (E0241), and sales tax (S9999) provided on January 25, 2021, by an out-of-network provider.
The enrollee asked the Plan to pay for a commode chair, bathtub rails, and sales tax. The enrollee says that they did not realize that they had to use a contracting durable medical equipment supplier. The Plan denied the enrollee's request. The Plan says rules for out-of-network care have not been met.
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. Medicare rules also say that Medicare does not reimburse separately for sales tax.
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a commode chair (E0163), bathtub rails (E0241), and sales tax (S9999) provided on January 25, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 4), oral hygiene instructions (D1330), comprehensive oral evaluation (D0150), 2D photographic images (D0350 x 4), drugs and medicaments (D9630), periapical x-rays (D0230 x 2), and bitewing x-rays (D0274) provided on June 23, 2021.
You asked the Plan to pay for the dental services. You say that you called the plan looking for a new dentist. You say that you called around and finally found a new dentist. You say that the provider told you they were in network. You say that the provider contacted your dental plan and was not told they were out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive out of network are 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, dental services you received out of network are not among those covered under this benefit. The record shows that the Plan provided in network dentists. The record also shows that the Plan did not advise that the provider in this case was in network. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341 x 4), oral hygiene instructions (D1330), comprehensive oral evaluation (D0150), 2D photographic images (D0350 x 4), drugs and medicaments (D9630), periapical x-rays (D0230 x 2), and bitewing x-rays (D0274) provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure (22899).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and not covered at this time.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered investigational at this time. More research is needed to show safety and efficacy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure (22899).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. 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.

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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 6, 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 procedure code 83630 is not supported.

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 83630 is lactoferrin, fecal; qualitative. 

We find that CPT code 83630 is not supported in the medical record. Specifically, there is no documentation of qualitative fecal lactoferrin testing. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on April 28, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is
not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 2, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the enrollee did not have a relationship with the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem.
We looked at the file and Medicare rules. In this case, the lab services were ordered by a physician who did not have an established relationship with the enrollee. The records do not show that the ordering physician was treating the enrollee. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional occupational physical therapy visits.
You asked the Plan to pre-approve 9 additional occupational physical therapy visits. You say that the services are 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 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 9 additional occupational physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee appears to be function at her baseline. The enrollee lives in a facility, where caregivers can provide needed assistance. As such, ongoing home health therapy services are not shown to be 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 9 additional occupational physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional occupational physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $100 copayment charged for ambulance transport provided on April 19, 2021.
You asked the Plan to waive this copayment. You say that in was not your choice to go the hospital and feel you should not have to pay the copayment. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.
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 $100 copayment for ambulance transport. You were provided with ambulance transport. 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 $100 copayment charged for ambulance transport provided on April 19, 2021.