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

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram and breast ultrasound you had on March 17, 2021.
You asked the Plan to waive the deductible for the diagnostic mammogram and breast ultrasound. You say that this was a preventive mammogram, so the deductible should not apply. The Plan denied your request. The Plan says you had not met your deductible at the time of this service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $395 deductible that applies to radiology services and x-rays. Records show that this mammogram and ultrasound were not ordered as screening. They were ordered as diagnostic tests due to breast tenderness at the 4-5 o' clock location of the left breast. Because this was not a screening test, the diagnostic testing cost sharing applies. That includes the deductible. Your Evidence of Coverage states that the deductible applies to radiology services and x-rays such as diagnostic mammograms. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 deductible that applies to radiology services and x-rays. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram and breast ultrasound was received on March 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram and breast ultrasound you had on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided to the enrollee on December 10, 2020.
You asked the Plan to pay for the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code.
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 pay for the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication in the office notes that the enrollee is taking insulin at all, so the criteria is not met. There is also no indication as to why a glucometer is not sufficient in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided to the enrollee on December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services.. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services.. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates by report imaging that there is multilevel severe spinal stenosis. The imaging report is not included in the submitted documentation. The record does not indicate that the enrollee does not require operative intervention at more than two levels. The Superion spacer is therefore not reasonable or 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 pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an unspecified preventive procedure (D1999) provided on February 15, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an unspecified preventive procedure. You say that the services should be covered. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. An unspecified preventive procedure 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 comprehensive oral evaluation, and an unspecified preventive procedure have not been met.
Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on August 18, 2020. Additionally, an unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an unspecified preventive procedure (D1999) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on January 8, 2021.

You asked the Plan to pay for the testing services. You say that the services were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing for suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

We looked at the file and the rules. In this case, there were insufficient medical records to show the results of the testing would be used in the determination of a specific diagnosis or treatment strategy. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic testing provided on January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus

You asked the Plan to pre-approve Tacrolimus. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self administered drug.

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 Tacrolimus
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on December 25, 2019.

You asked the Plan to pay for the testing services. You say that the test was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says services that are not medically necessary are not covered.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications. 

We looked at the file and Medicare rules. The records provided show that the enrollee was tested for EGFR. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on December 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on November 16, 2020.

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 records do not support the services 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. 

We find that CPT codes 95861, 95868, 95927, 95938, 95939 are not supported in the medical record. Specifically, the billed place of service (POS 15) is not supported in this case. As the services were received in a facility setting, the payment would be included in the payment to the facility. 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 hospital services provided to the enrollee on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 7, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that this service was provided to prevent and reduce the risk and advancement of gum disease. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says scoliosis is a contraindication for this device.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on December 18, 2020.
You asked the Plan to pay for the testing services. You say that you do your part to provide timely testing and results. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing for suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The screening panel was requested solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from April 8, 2021, to April 12, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you had an emergency room visit and were admitted to the hospital. You say that the copay is waived if you are admitted. The Plan denied your request. The Plan says that only the emergency room copayment is waived if you are admitted, not the copayment for the inpatient hospital services. The Plan says that you were charged the inpatient hospital copayment 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 $275 copayment per day for days 1-5 for inpatient hospital care.

Records show that you were in the hospital for four days. You have been asked to pay a $275 copayment per day for the inpatient hospital care. 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 inpatient hospital care you received from April 8, 2021, to April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fitting of spectacles, except for aphakia (92341) provided on March 12, 2021.

You asked the Plan to pay for the vision services. You say that the patient did not have any input in choosing who would be his optometrist, and instead he blindly relied on the facility staff to ensure that he would have a vision exam, which was of high necessity. The Plan denied your request. The Plan says eyeglasses are not a Medicare covered benefit.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan covers routine eyeglasses. The Plan contract does not have a provision for separate coverage of fitting of spectacles. Therefore, we decided that the Plan does not have to pay the fitting of spectacles, except for aphakia (92341) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you do not trust the provider's billing practices, and that you were left responsible for the provider charges. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Please note, the Plan confirmed that the provider has written off the charges and will not be billing you for the denied charges.
Therefore, we decided that the Plan does not have to pay for the office visit provided on April 21, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care received on March 29, 
2021. 
 
You asked the Plan to waive the copayment for the services. You say that you went to the emergency room, but 
did not see a doctor. The Plan denied your request. The Plan says the claim in question processed correctly 
according to the 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the services. The services fall 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 emergency care received on 
March 29, 2021
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a coronary computed tomography angiogram (CCTA) with calcium scoring.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have had sharp pain near your right chest for a year. The echocardiogram and stress test results were normal. The test is being requested to determine lipid therapy. The services are reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a coronary computed tomography angiogram (CCTA) with calcium scoring.
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 waive the copayment for inpatient mental health care services you 
received from March 16, 2021, to March 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you cannot 
afford this copayment and you are on the low income financial assistance program. The Plan denied your 
request. The Plan says you were charged this copayment 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 $100 
copayment per day for days 1-7 for inpatient mental health care.  
 
You have been asked to pay a $100 copayment per day for days 1-7 for the inpatient mental health services. 
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 inpatient mental health care services you 
received from March 16, 2021, to March 25, 2021.  
 
Your complaint about the Plan's financial assistance program and what costs if covers is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper eyelid blepharoplasty.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty 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 pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have
dermatochalasis. There is no documentation that you have a margin reflex distance of 2.0 millimeters or less.
The photographs are insufficient to support that the criteria are met. The blepharoplasty is therefore not
reasonable or 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 pre-approve an upper eyelid blepharoplasty.