Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2 of the dental extractions provided on December 6, 2019.You asked the Plan to pay for2 of the dental extractions. You say that you called the Plan and were told that extractions were covered.The Plandenied your request. The Plan says the number of extractions you are requesting coverage for exceeds the benefit limits.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 coverage for extractions is limited to 2 per calendar year. The records show that the Plan has agreed to pay for 2 dental extractions you received on December 6, 2019. This means that your benefit for dental extractions in the 2019 calendar year has been exhausted.Therefore, we decided that the Plan does not have to pay for2 of the dental extractions provided on December 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 25, 2019.You asked the Plan to waivethe copayment forthe ambulance transport. You say that you were informed you wouldn't have to pay for an ambulance. You say that you do not agree with the cost share.The Plan denied your request. The Plan says the copayment 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 each Medicare-covered one-way trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 forthe ambulance transport provided on November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forCT scan and the myelography lumbar injection provided on August 30, 2019.You asked the Plan to waive the copayments forthe CT scan and the myelography lumbar injection. You say that this is one test where they inject dye into the spine and take a CT scan. You say you should not be charged for two separate tests. 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 $150 copayment for each in-network Medicare-covered diagnostic radiology service and a $175 copayment for each in-network Medicare-covered outpatient hospital facility visit. You have been asked to pay a $150 copayment for the CT scan and a $175 copayment for the myelography lumbar injection. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services andsupplies" benefit category. The myelography lumbar injection falls within the "Outpatient hospital services" benefit category. The record shows the CT scan is considered a radiological diagnostic test and the myelography lumbar injection is considered a surgical procedure. 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 copayments forCT scan and the myelography lumbar injection provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient dental surgery, maxillofacial consult to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe outpatient consult. You saythat you have had lesions in your mouth for over 2 years and you need to be sent to someone who can help you.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has confirmed that there are specialists in-network who can provide the requested 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe outpatient dental surgery, maxillofacial consult to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts and custom shoes.You asked the Plan to pre-approve the foot inserts and custom shoes. You say that you were approved for orthotics you previously received in 2018 which were made to reduce your foot pain and increase your walking capability. You say that you do not need a leg brace. You say that the plan felt these items were valid in 2018, and that you should be treated the same way this year and in the future.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 pre-approve foot inserts and custom shoes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care (99232) provided on October 15, 2019 through October 23, 2019.You asked the Plan to pay forthe subsequent hospital care. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed code denied because the claim did not include the appropriate primary, first-listed or principal diagnosis.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99232 is not supported in the record. Specifically, per ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, the diagnosis code on the claim is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (99232) provided on October 15, 2019 through October 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating facility on December 6, 2019.You asked the Plan to waive the copayment foran emergency room visit. You say that you do not want to pay for this because you feel like the doctor didn't spend enough time with you. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since emergency room services were provided the correct copayment has been applied. An emergency room visit falls within the emergency care 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 an emergency room visit provided by a participating facility on December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe acute inpatient hospital care.You asked the Plan to pre-approveacute inpatient hospital care. You say that you would like reconsideration because it is medically necessary to admit the member preoperatively for IV hydration.The Plan denied your request. The Plan says inpatient admission is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found both pre-procedure hydration and post procedure monitoring of renal function can reasonably be expected to be completed in a time period of less than two midnights and do not require that the enrollee be admitted to inpatient status. At the time of inpatient admission, the admitting physician cannot reasonably expect that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of pembrolizumab (Keytruda).You asked the Plan to pre-approvepembrolizumab. You say that given the unusual nature of the enrollee's condition, poor response to standard therapy, and molecular features, you are requesting treatment with pembrolizumab.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee's condition does not meet off-label criteria for use of pembrolizumab.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 pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for use of pembrolizumab. Our physician reviewer found this drug is not approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. The use of this drug is not supported by major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Although pembrolizumab is a reasonable choice for men with metastatic disease who are found to have deficient mismatch repair (dMMR), ongoing work is needed to identify other candidate biomarkers to identify patients who are appropriate candidates for immune-based therapy approaches.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of pembrolizumab (Keytruda).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approv e a CT Scan of the thorax (71250) and CT Scan of the abdomen and pelvis (74176).You asked the Plan to pre-approve the CT Scans. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the CT Scans are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT Scans. Our reviewer says that the request for CT of thorax, abdomen and pelvis is medically reasonable and necessary. Our physician reviewer found the clinical concern is for malignancy or infection causes night sweats and abdominal pain.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 CT Scans have been met. Therefore, we decided that the Plan has to pre-approve a CT Scan of the thorax (71250) and CT Scan of the abdomen and pelvis (74176). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep therapy equipment (E0471) and sleep therapy accessories (E0562).
You asked the Plan to pre-approve sleep therapy equipment and accessories. You say that you are appealing the denial of the enrollee's ASV machine and supplies. You have reviewed the coverage policy however, the best treatment for this enrollee's falls outside the established policy. The Plan denied your request. The Plan says the medical information submitted does not support medical necessity.
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 sleep therapy equipment and accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee is not noted to have severe COPD or a restrictive thoracic disorder. Furthermore, his diagnostic sleep test results and PAP compliance downloads did not demonstrate the presence of central sleep apnea or complex sleep apnea. Rather he's only noted to have primary obstructive sleep apnea (based on current diagnostic standards). In as much the requested ASV unit would not meet the requirements of the LCD for coverage and therefore would not be medically necessary.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuation of inpatient hospital care.You asked the Plan to pre-approvethe continuation of inpatient hospital care. You say that the records provided support the need for a continued inpatient hospital stay.The Plan denied your request. The Plan says the clinical information provided does not support the medical necessity of the continuation of an inpatient level of care.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 continuation of inpatient hospital care. Our reviewer says that the inpatient level of care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is presently medically stable. The enrollee was treated for SVT and suspected AVNRT which has resolved. The enrollee was unresponsive to adenosine but eventually responded to IV Metoprolol. The enrollee had thrombocytopenia, which resolved. The enrollee has remained medically stable on her medical regimen, tolerating an oral diet. The enrollee's work-up is complete and she requires assistance with all activities of daily living. The enrollee does not require any further inpatient diagnostic studies or therapeutic interventions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuation of inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care (98943 and 98940).You asked the Plan to pre-approve the chiropractic care. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records do not include any evidence of subluxation.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. We askedour 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 chiropractic care Our reviewer says that there are no chart note/examination findings supporting a subluxation. Our physician reviewer found x-rays revealed spondylosis and an MRI, dated December 17, 1998 revealed disc degeneration and hypertrophic spurring, arthritic type findings, for which chiropractic can do little and, any chiropractic treatment would be to prevent deterioration of a chronic condition (maintenance therapy). Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines.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 chiropractic care have not been met.Therefore, we decided that the Plan does not have to pre-approvechiropractic care (98943 and 98940)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility(SNF) admission.You asked the Plan to pre-approvethe SNF admission. You say that your apartment is on the third floor and you would not be able to walk up the stairs and going to the rehab is so you could accomplish that.The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0800).
You asked the Plan to pre-approve a power wheelchair. You say that you cannot walk long distances and a power wheelchair would allow you to go to church and to go shopping. The Plan denied your request. The Plan says the submitted medical records do not show that you need this.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that you are requesting this item primarily for transportation outside your home. The records submitted do not show that you need this item for inside your home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory testing received on December 12, 2019.You asked the Plan to waive the copayment forthe laboratory testing. You say that you disagree with the plan's decision.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 $5 copayment for lab tests. You havebeen asked to pay a $5 copayment for the laboratory testing. The laboratory testing falls 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 copayment forthe laboratory testing received on December 12, 2019.