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

We decided that the Plan does not have to pre-approve Lumigan 0.01% eye drops.
You asked the Plan to pre-approve Lumigan 0.01% eye drops. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan 0.01% eye drops.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on November 15, 2019. You asked the Plan to waive the copayment for these services. You say that you thought you would have a lower cost share. The Plan denied your request. The Plan says the copayment 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 $250 copayment for Medicare-covered outpatient surgery in a hospital outpatient facility. Review of the file shows that you received outpatient surgical services on November 15, 2019. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered outpatient surgery in a hospital outpatient 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 outpatient hospital services rendered to you on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto tablets.
You asked the Plan to pre-approve Entresto. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage for this medication is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto tablets.
Appeal type: Drugs
Decision: Unfavorable

e decided that the Plan does not have to pre-approve Gleostine Cap 100mg.You asked the Plan to pre-approveGleostine Cap 100mg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plandoes not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveGleostine Cap 100mg.Benefits for Gleostine Cap 100mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the cholecystectomy provided on August 23, 2019.
You asked the Plan to reduce the coinsurance for the cholecystectomy. You say that you were told the copayment would be around $225 for the surgery. The Plan denied your request. The Plan says you have been charged 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 20% coinsurance for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay $926.06 which is 20% of the allowed amount for the cholecystectomy. The allowed amount is $4,630.32. ($4,630.32 x 20% = $926.06). The cholecystectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 reduce the coinsurance for the cholecystectomy provided on August 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services (96130, 96131, 90791).
You asked the Plan to pre-approve the mental health services. You say that the services are medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
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 mental health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review the records provided in the information provided there is no evidence that this patient requires psychological testing and could have been seen by a physician to determine his possible risk of abuse of medication. 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 mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services (96130, 96131, 90791).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthotics provided on October 10, 2019 by an out of network provider.You asked the Plan to pay forthe orthotics. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the doctor is out-of-network and a podiatrist who therefore should not self-refer.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 incases 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 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. Physicians cannot self-refer. 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 orthotics providedon October 10, 2019 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cardiac catheterization provided on November 1, 2019.You asked the Plan to waive the copayment forthe cardiac catheterization. You say that you would like to be repaid the $3,800 you paid for the procedure.The Plan denied your request. The Plan says you have been charged 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 $295 copayment. for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the cardiac catheterization.The cardiac catheterization falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the Plan is reimbursing you $3,505. ($3,800 -$295 copayment = $3,505). 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 forthe cardiac catheterization provided on November 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe medical services provided out of network. You say that  The Plan denied your request. The Plan says is not contracted with billing with TIN 461257838 and NPI 1356338412 for this line of business.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 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 medical services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSight Psychotropic Assay rendered to on September 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the GeneSight assay is covered when specific criteria are met.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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent moderate major depressive disorder. There are no clinical records in the submitted case file. The submitted documentation does not show that the enrollee has failed or is currently failing at least one neuropsychiatric medication, or that the provider is contemplating an alteration in a neuropsychiatric medication treatment. The criteria for coverage are not met and the GeneSight testing was not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe GeneSight Psychotropic Assay rendered on September 25, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided to the enrollee on May 9, 2019.
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says an assistant surgeon was not medically necessary for the services provided.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
In this case, you billed assistant surgery services for CPT code 36561. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 assistant services. Our physician reviewer found that the service at issue is not a procedure that requires a surgical assistant. There was nothing unusual, complicated about the patient or procedure that warrants a mandated surgical assistant. Therefore, the services were not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided to the enrollee on May 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on October 7, 2019.
You asked the Plan to pay for foot orthotics. You say that you are trying to avoid surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a transfer bench purchased on September 2, 2019, or the knee walker purchased on August 30, 2019.
You asked the Plan to reimburse you for a transfer bench and knee walker. You say that because of an injury you needed the transfer bench and the knee walker. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that transfer bench are not covered because they are not primarily medical in nature. Knee walkers are not covered by Medicare. While a transfer bench and knee walker may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Also, durable medical equipment purchased privately through agents are not eligible for coverage by your Medicare governed health plan. Therefore, we decided that the Plan does not have to reimburse you for a transfer bench purchased fon September 2, 2019, and the knee walker purchased on August 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73551) provided to the enrollee on
October 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare does not pay separately for this service.
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 73551 is "Radiologic examination, femur."
We find that CPT code is not supported in the medical record. Specifically, this code is a column II procedure
to the column I procedure already billed on this claim - CPT 73552. This code cannot be billed separately.
Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for radiology services (CPT 73551) provided to the
enrollee on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on November 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for 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 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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. 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 the medical services provided to the enrollee by an out-of-network provider
on November 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 00145) provided to the enrollee on September 28, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the anesthesia chart and other notes do not support the units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 00145 is "Anesthesia for procedures on eye; vitreoretinal surgery." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found that the medical records provided note anesthesia start time as 9:05 am and the stop time as 10:37, a total of 92 minutes. CPT 00145 has a value of 6 base units and the rest of the units are based on 15-minute increments of time. This does not equate to 108 units, therefore the units billed cannot be verified leaving CPT code 00145 QX (108 units) ineligible for reimbursement consideration. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 00145) provided to the enrollee on September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for group therapeutic procedures (97150) provided by a chiropractor from September 25, 2019 to November 13, 2019.You asked the Plan to pay for group therapeutic procedures. You say that these services were medically necessary.The Plandenied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forgroup therapeutic procedures (97150) provided by a chiropractor from September 25, 2019 to November 13, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #21, prefabricated post and core in addition to crown (D2954) for tooth #21, and endodontic therapy (D3320) for tooth #21.You asked the Plan to pre-approvethe crown, prefabricated post and core, and endodontic therapy. You say that the enrollee does not want to extract any more teeth because he already has too many missing teeth.The Plan denied your request. The Plan says the x-ray of tooth #21 does not show there is enough bone around your tooth. The Plan also says that tooth #21 must have 50% bone support to approve these services, and the x-ray shows that tooth #21 does not have50% bone support.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 the crown, prefabricated post and core, and endodontic therapy 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 the crown, prefabricated post and core, and endodontic therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found the crown is not medically reasonable and necessary. Long term prognosis is poor due to excessive bone loss. Our reviewer found that the prefabricated post and core in addition to crown is not medically reasonable and necessary as the crown has a poor long term prognosis and the service is a dependent service on the crown. Our physician reviewer also found that endodontic therapy is not medically reasonable and necessary because the restorative aspect of tooth #31 is compromised and due to the lack of bone support has a poor long term prognosis.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 the crown, prefabricated post and core, and endodontic therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown (D2750) for tooth #21, prefabricated post and core in addition to crown (D2954) for tooth #21, and endodontic therapy (D3320) for tooth #21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces (D7311).
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions. You say that the service is necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.
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 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces (D7311).