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

We decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generator system.You asked the Planto pre-approvethe Optimizer system. You say that the requested service is supported to be clinically helpfulin the available research.The Plandenied your request. The Plansaysthis is noncovered based on a Local Coverage Determination (LCD).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 Optimizer system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the patient has refractory congestive heart failure. In this circumstance, treatment with the Optimizer System (CPT 0408T) device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). Therefore, the efficacy of the Optimizer System is still uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 Optimizer system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generator system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveambulance transportation.You asked the Plan to pre-approveambulance transportation. You say that you need transportation to dialysis.The Plan denied your request. The Plan says the requested service is not on thelist of covered benefits.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. In this case, there is insufficient medical information that shows transportation by other means is contraindicated. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approveambulance transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transesophageal Echocardiography (93318).
You asked the Plan to pre-approve the Transesophageal Echocardiography. You say that the Transesophageal
Echocardiography is medically necessary. The Plan denied your request. The Plan says the enrollee has no
symptoms which would make the Transesophageal Echocardiography medically necessary.
The Plan follows Medicare rules. Medicare rules say that Transesophageal Echocardiography is covered when
Transthoracic Echocardiography is felt not to give adequate information.
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 Transesophageal Echocardiography.
Our reviewer says that the requested test is not medically necessary. Our physician reviewer found the enrollee
is asymptomatic with normal cardiac exam and a normal EKG. A transthoracic dobutamine stress
echocardiogram done in Sept 2018 was showed normal left ventricular function, normal valve function and no
ischemia. There is no report that this transthoracic study was not technically adequate.
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 Transesophageal Echocardiography have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Transesophageal Echocardiography (93318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe extraction of tooth (D7140).You asked the Plan to pre-approvethe extraction of tooth. You say that the service is necessary for the condition.The Plan denied your request. The Plan says the service is not a covered benefit under the 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 Plandoes not have to pre-approvethe extraction of tooth (D7140)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveneuropsychiatric testing (96113, 96138, 96132, 96116) to be provided by an out of network provider.You asked the Plan to pre-approvethe neuropsychiatric testing. You say that the services are medically necessary.The Plan denied your request. The Plan says there are network providers available that can provide these services.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approveneuropsychiatric testing (96113, 96138, 96132, 96116) to be provided by an out of network provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary.The Plan denied your request. The Plan say sthe clinical information provided does not describe PSA results indicative of prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records shows a clinical diagnosis of BPH. PSA levels have been:  9/21/18 (2.0), 4/14/20 (0.9) and 10/7/20 (1.3). The guidelines require a level of a least 3.0. Based on this history the medical necessity of MRI of the pelvis has not been established.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0652).You asked the Plan to pay fora pneumatic compression device. You say that the records should support the necessity of the requested service in dispute.The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. The records show that symptoms may be caused by something other than lymphedema and also that you do not always wear your compression stockings as prescribed. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrolleehad at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0652)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
(K0554, K0553).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this should be covered. The Plan
denied your request. The Plan says the record does not show that you are insulin-treated.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle
Libre continuous glucose monitor (CGM) (K0554, K0553).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the IUD provided on November 14, 2019.
You asked the Plan to pay for the IUD. You say that the IUD was needed to treat Trigeminal Neuralgia. The Plan denied your request. The Plan says it is not being used to diagnose or treat illness or injury.
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 looked at the file, and Medicare rules. The documentation provided does not show that Levonorgestrel-releasing intrauterine contraceptive system (mirena) was used for a condition that is indicated for coverage. Based on this information, we decided that Medicare rules for coverage of the IUD have not been met. Therefore, we decided that the Plan does not have to pay for the intrauterine contraceptive device (IUD) provided on November 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology services with CPT code 73020 provided on August 20, 2020.You asked the Plan to pay forCPT code 73020. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 73020 has a bundled relationship with code 73030 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe radiology services with CPT code 73020 provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefreesoft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in graft (D4277), free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site (D4278), and surgical stent (D5982).You asked the Plan to pre-approvefree soft tissue graft procedures and surgical stent. You say that the services should be covered.The Plan denied your request. The Plan says the services are not covered 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 pre-approvefree soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in graft (D4277), free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site (D4278), and surgical stent (D5982)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).You asked the Plan to pre-approvethe custom fabricated abutments and implant supported crowns. You say that these services are needed in order to complete the implant procedures.The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.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-approvetwo custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick external catheter.
You asked the Plan to pre-approve the requested device. You say that the device is medically necessary. The
Plan denied your request. The Plan says this equipment is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that urological supplies are only covered under
certain medical indications.
We looked at the file and Medicare rules. The records provided do not indicate the device is being requested as
an alternative to an indwelling catheter. Based on this information, we decided that Medicare rules for coverage
of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Purewick external catheter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown, core buildup, including any pins when
required, and resin-based composite.
You asked the Plan to pre-approve the crown, core buildup, and resin-based composite. You say that the crown
and core buildup are for tooth #15. You also say that the resin-based composite should only be on the notice
once. The Plan denied your request. The Plan says the crown and core buildup are not covered benefits. The
Plan also says that your resin-based composite benefit has 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, crown and core buildup are not among
those covered under this benefit. The Plan contract also clearly states that resin-based composite is limited to
one procedure per calendar year. The record shows that you were approved for a resin-based composite for
tooth #26 on October 13, 2020, and your resin-based composite benefit has been exhausted. Therefore, we
decided that the Plan does not have to pre-approve a crown, core buildup, including any pins when required,
and resin-based composite.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial lower denture (D5214).You asked the Plan to pre-approvethe dental item. You say that the enrollee has an existing lower denture. You say that the enrollee has not been wearing it due to pain on their mandible and tongue with sores and digestive problems. You say that the enrollee's denture has been adjusted and repaired previously but is not fitting well, causing food trap and ulcers. You also say that the enrollee needs a new denture to help with these issues.The Plan denied your request. The Plan says 1 lower denture is covered every 5 calendar years. The Plan 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 lower denture every 5 calendar years has been reached. The record shows that the Plan paid for a lower denture that the enrollee received on September 9, 2016.Therefore, we decided that the Plan does not have to pre-approvea partial lower denture (D5214)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 areaurgent care and pre-approved care.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. 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 forthe laboratory services provided on August 26, 2020 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the outpatient surgery services provided.

You asked the Plan to waive the co payment for the outpatient surgery services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an outpatient surgical procedure on the date of service at issue in this appeal. The Plan says that the correct co payment has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Outpatient surgery.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgery services provided in an Ambulatory Surgical Center on June 18, 2020. You have been asked to pay a $250 copayment for the outpatient surgery services. The outpatient surgery services fall within the Outpatient surgery 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 topay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe imaging services provided on July 22, 2020.You asked the Plan to waive the copay forthe services provided. You say that you have no copay for specialists.The Plan denied your request. The Plan says the copay was applied 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 $95 copay for diagnosticradiologicaltests. The file shows that you received a computed tomography (CT) scan. You have been asked to pay a $95 copay for the services provided. The services fall within the outpatient diagnostic tests 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 copay forthe imaging services provided on July 22, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 31, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon August 31, 2020.