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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E0956, E2606, K0108) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that supports that the requested power wheelchair accessories (E0956, E2606, K0108) are eligible for coverage under Medicare guidelines. The records do not document significant postural asymmetries necessitating a positioning seat cushion (E2606) or positioning accessory (E0956). Switch Fender Lights (K0108) are a convenience item and not covered by Medicare. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E0956, E2606, K0108) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclophosphamide capsule 50 MG
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says coverage for this drug may be provided through a Medicare Part D 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 Cyclophosphamide capsule 50 MG.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the periapical x-ray. We decided that the Plan does not have to pay for
the cone beam CT.
You asked the Plan to pay for the cone beam CT. You say that you were told my several plan representatives
that this service would be covered. The Plan denied your request. The Plan says cone beam CT is not listed as a
covered service. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan also says that the
frequency limit has been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Additionally, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the
Plan's coverage rules apply in this case.
We decided that the Plan has to pay for the periapical x-ray.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that the Plan denied the periapical x-ray based on frequency limit. The
Plan did not provide documentation that substantiates this. Without this information, we cannot determine that
the frequency limit has been exceeded. Therefore, we decided that the Plan has to pay for the periapical x-ray
provided on February 18, 2021.
We also decided that the Plan does not have to pay for the cone beam CT.
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT
provided on February 18, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision of a benign lesion provided on February 23, 2021.
You asked the Plan to waive the copayment for the excision of a benign lesion. You say that you had the procedure done in your doctor's office and feel that it should not be considered a surgical procedure. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $335 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received the excision of a benign lesion on February 23, 2021, at an outpatient hospital facility. The excision of a benign lesion is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $335 copayment.
You have been asked to pay a $335 copayment for the excision of a benign lesion. The excision of a benign lesion falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 excision of a benign lesion provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. You say that the enrollee is having symptoms in the lumbar spine. The Plan denied your request. The Plan says there is no documentation of 2 diagnostic medial branch blocks to the levels to be treated.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested services. Our physician reviewer found that in this case the provided records do not indicate the level to be treated. The records do not indicate previously treated levels or levels that received a diagnostic block. The records are insufficient to make a determination whether the coverage criteria are satisfied. Therefore, the requested services are not medically reasonable or necessary at this time.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that an IRF is the appropriate placement for this enrollee to receive the proper care and rehabilitation that is necessary for the enrollee to regain full function. The Plan denied your request. The Plan says the enrollee is not currently stable enough for IRF services and continues to require services at the acute care facility for recurrent issues. Once the enrollee is clinically stable, the enrollee may be considered for a transfer to an appropriate lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for nor is there a reasonable expectation that the patient could tolerate an intensive rehabilitation program. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Darzalex Faspro to be used in conjunction with Carfilzomib.
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says that the enrollee has previously experienced disease progression while on a regimen containing daratumumab.
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 requested drug. Our physician reviewer found that the National Comprehensive Cancer Network Guidelines states that the requested drug may be used as a single agent or in combination with other systemic therapies where intravenous daratumumab is recommended. Daratumumab is indicated as therapy for previously treated multiple myeloma for relapse or for progressive disease in combination with carfilzomib and dexamethasone. In this case, the record indicates that the enrollee has multiple myeloma. The enrollee has had disease progression and recurrence. The guidelines do not contain a contraindication for previous use of the requested drug. The elements of the coverage rule are satisfied. The requested service is recommended. 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 requested drug have been met. Therefore, we decided that the Plan has to pre-approve Darzalex Faspro to be used in conjunction with Carfilzomib.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 20, 2021 and billed under code 99601.
You asked the Plan to pay for this code as billed. You say that this claim should be paid. The Plan denied your request. The Plan says code 99601 has a status code indicator of "I" for Medicare claims. Medicare uses another code for reporting of and payment of 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, code 99601 has a status code indicator of "I" which prevents payment under the Medicare payment schedules. A corrected claim with an appropriate Medicare code is required. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on January 20, 2021 and billed under code 99601.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a heart positron emission tomography (PET) scan
You asked the Plan to pre-approve a PET scan. You say that after careful review of the testing and office notes, you ask that the MPI PET be approved so that proper cardiac medical management could be done for this patient. The Plan denied your request. The Plan says that the requested heart PET scan is not indicated or medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in terms of medical necessity, the enrollee has an intermediate risk Duke treadmill score of 0.5 and would therefore qualify, based on guidelines, for further definitive evaluation for ischemic heart disease. As it has been more than two years since the last ischemia evaluation and although it is likely that the stress echo findings may be "false positive" again, given the recurrent exertional dyspnea and the history of prior mild atherosclerotic disease, and in the setting of an intermediate risk Duke treadmill score, repeat PET scanning would be considered reasonable and conforms to the CMS NCD rules.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have been met. Therefore, we decided that the Plan has to pre-approve a heart positron emission tomography (PET) scan
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are no acute psych problems that require acute care.
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 the requested services. Our physician reviewer found that active treatment was not taking place. The services are not reasonably expected to improve you condition or for the purpose of diagnosis. An individualized treatment was not found; however, the entire record is not present.
Based upon review of the records, you were not shown to be a danger to self or others. There were no signs of auditory or visual hallucinations. You are noted to be cooperative and compliant with treatment while not showing any acute threat to safety. Therefore, the requested inpatient services are not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria has not been 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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you are not checking four times a day, and you are not taking insulin three times a day, so the criteria is
not met. There is no evidence why a traditional glucometer would not be sufficient.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Freestyle Libre 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and a filling (D2335) provided on February 3, 2021.
You asked the Plan to pay an additional amount for a limited oral evaluation, and a filling. You say that the services at issue were necessary. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate for the filling therefore no additional payment can be made. The limited oral evaluation 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and a filling have not been met. Specifically, the allowed amount for a filling for an out-of-network provider were paid by the plan. Additionally, a limited oral evaluation is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and a filling (D2335) provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital dentistry services specified as teeth extractions.
You asked the Plan to pre-approve hospital dentistry services specified as teeth extractions. You say that it is necessary for you to receive your dental treatment in a hospital. The Plan denied your request. The Plan says these are routine services that are safely performed in an oral surgery office.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve hospital dentistry services specified as teeth extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation -
established patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110)
provided January 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to provide additional payment for the periodic oral exam, bitewing x-rays and dental
cleaning. You say that you expected the services to be covered in full. The Plan denied your request. The Plan
says the claims have processed correctly. Since the services were rendered by an OON provider you are
responsible for the difference between the Plan's allowed amount and the total amount charged by the provider.
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 periodic
oral exam, bitewing x-rays and dental cleaning when the services up to the Plan's allowed amount.
We looked at the file and Medicare rules. In this case you received dental services from an OON provider. The Plan has provided reimbursement for the services up to the Plan's allowed amount. Therefore, we decided that
the Plan does not have to provide additional payment for the periodic oral evaluation - established patient
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided January 6, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown, two retainer crowns, pontic, two first intraoral periapical x-rays, and two additional intraoral periapical x-rays provided from August 4, 2020, to September 22, 2020.
You asked the Plan to pay for the prefabricated post and core, retainer crowns, pontic, and intraoral periapical x-rays. You say that you would like some relief paying for these services, for the enrollee's health and wellbeing. The Plan denied your request. The Plan says the prefabricated post and core, retainer crowns, and pontic are not covered services. The Plan also says that your benefit for intraoral x-rays has been satisfied and the frequency limitation has been exceeded.
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, prefabricated post and core, retainer crown, pontic are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on August 4, 2020, which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown, two retainer crowns, pontic, two first intraoral periapical x-rays, and two additional intraoral periapical x-rays provided from August 4, 2020, to September 22, 2020.