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

We decided that the Plan does not have to pay for surgical services (CPT 27685) provided to the enrollee on September 25, 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 requested service code is not substantiated by the clinical documentation in the medical records submitted for review.
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 27685 is "lengthening or shortening of a tendon, of the leg or ankle, for a single tendon (separate procedure)." We asked our coding 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 supported by the medical records. Our coding reviewer found CPT 27685 would be covered if different session, site, compartment or incision. The operative report submitted does not support "separate session", therefore is not covered. Bundled procedures are not covered separately if performed through same incision. We looked at this coder'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 surgical services (CPT 27685) provided to the enrollee on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator.
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that you need this equipment. The Plan denied your request. The Plan says that you are not undergoing a multiple level fusion, nor do you have a previously failed fusion at the same site.
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered if the above 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 a spinal electrical osteogenesis stimulator. Our reviewer says that a spinal electrical osteogenesis stimulator is not medically reasonable and necessary. You are only having a one-level cervical fusion. There is a previously healed neck fusion. The stimulator is not medically needed. Our physician reviewer found that your condition does not meet Medicare criteria for a spinal electrical osteogenesis stimulator. 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 spinal electrical osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator.
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 or pay more for the endodontic therapy.

You asked the Plan to pay for the prefabricated post and core and to pay more for the endodontic therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says your calendar year maximum had been reached.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,500 combined allowance for supplemental preventive and comprehensive services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown or pay more for the endodontic therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy. Iliac crest autograft is the gold standard. Our physician reviewer found that you condition does not meet criteria for coverage of these services. 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 bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker and sales tax purchased from an online retailer for the enrollee for use in skilled nursing facility.

You asked the Plan to pay for this wheelchair and sales tax. You say that this walker was medically necessary for the enrollee to use in a skilled nursing facility. The Plan agreed to pay for the wheelchair but denied the sales tax. The Plan should follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Medicare also requires enrollees to use providers who are eligible to receive Medicare payment structures.

The records show that this wheelchair was specifically purchased for use in a SNF from an online retailer which is a public retail provider and not an eligible Medicare durable medical equipment provider. The Plan states they approved payment of the wheelchair and denied the sales tax. It should be noted they are not required to pay for the wheelchair or the sales tax in this case. Therefore, we decided that the Plan does not have to pay for a walker and sales tax purchased from an online retailer for the enrollee for use in skilled nursing facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 pre-approve 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis of the left foot and had an amputation of the left foot. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Venofer 200mg/10ml infusion (J1756).
You asked the Plan to pre-approve Venofer. You say that the Venofer is medically necessary. The Plan denied your request. The Plan says that a tier exception is not available for Part B drugs.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the copy of the original Denial of Coverage the plan provided for review is not translated to English for the IRE to review. Upon translation, this denial appears to be a medical denial. The provider's appeal request is based on medical necessity. It does not appear to be a request for a tier exception. The plan's appeal denial is for a tier exception. The plan did not address medical necessity in the appeal review. Insufficient documentation was provided to the IRE to support the denial. Therefore, we decided that the Plan has to pre-approve Venofer 200mg/10ml infusion (J1756).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee.

You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need 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 the provided record does not indicate that the enrollee checks her glucose four or more times a day nor that insulin is frequently adjusted.

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 provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer 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 had network providers available who could have provided 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 for lab tests provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were told that you would not owe a copayment. 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 $200 copayment for nuclear medicine radiological services and facilities.

You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided by a participating provider.

You asked the Plan to waive the copayment for urgent care services. You say that you do not agree with this copayment. 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 urgently needed services/emergency department of a hospital.

You have been asked to pay $65 which is less than your copayment amount of $90 for urgent care services. Urgent care services fall within the urgently needed services/emergency department of a hospital 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 urgent care services provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasounds.

You asked the Plan to waive the coinsurance for the ultrasounds. You say that you have never had to pay for an ultrasound in the past. You say that you were unaware you have a copayment for ultrasounds. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.

You have been asked to pay $54.76, which is 20% of the allowed amount for the ultrasounds. The allowed amount is $273.81 (20% x $273.81 = $54.76). The ultrasounds fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 coinsurance for the ultrasounds.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy.

You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventative colonoscopy and you should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether or not the colonoscopy was preventative or not. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown.

You asked the Plan to pay for the dental service. You say that the crown should be covered at 50%, not 40%. You say that the Plan should pay the difference in the cost. The Plan denied your request. The Plan says the crown is listed as a major dental service. The Plan also says that there is a 60% coinsurance for the crown.

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 and the crown is a covered service, there is a 60% coinsurance that you are responsible for. Therefore, we decided that the Plan does not have to pay for the crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve catheter supplies. You say that you need the financial help that comes with this out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available who also offer financial aid.

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 durable medical equipment to be provided by an out of network (OON) provider.

Please contact the Plan for a list of in-network providers available for these services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that you saw a physician assistant not a specialist. You say that you shouldn't be charged a $45 specialist copayment. 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 $45 for each covered office visit to other providers for urgently needed services.

You have been asked to pay a $45 for the office visit. The office visit falls within the "Urgently needed services" benefit category. The records show that you were treated at an urgent care facility. 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 office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the member liability for the crowns (D2750 x 2) and core build up (D2950 x 2).

You asked the Plan to waive the member liability for the dental services. You say that you should not have to pay the $2,167 member responsibility. The Plan denied your request. The Plan says there is a $2,000 combined allowance for supplemental preventive and comprehensive dental services every year. The Plan also says that the allowance has been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are a covered service, the annual allowance of $2,000 has been exhausted. The record shows that the Plan paid $147 for dental services, $714 for dental services and $1,139 towards dental services that you received on the date of service in this case. The Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to waive the member liability for the crowns (D2750 x 2) and core build up (D2950 x 2).