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

We decided that the Planhasto pre-approveseptoplasty nose surgery for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe plan does not services that are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested services areconsidered medically reasonable and necessary in this case. Our physician reviewer found a septoplasty is often performed for the symptoms of nasal obstruction, difficulty breathing through the nose, inability to tolerate CPAP, and snoring. However, a septoplasty can also be indicated if another procedure needs to be performed. For example, a septoplasty may need to be performed to access the ostiomeatal complex, the maxillary sinus, the sphenoid sinus, the skull base, the pitutiary gland, etc. In this case, the enrollee's nasopharynx needs to be accessed in another procedure but cannot be done due to the deviated septum. When denying this request, the premise was that the surgery was being done to relieve symptomatic obstruction. However this is inaccurate. The surgery is being done to provide access to the posterior nose. Therefore, medical management with nasal sprays is inappropriate because it will not change the shape of the septum, nor relieve a fixed obstruction. The septoplasty is medically reasonable and 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 surgery have been met.Therefore, we decided that the Planhas to pre-approveseptoplasty nose surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 14,
2020 through January 21, 2020 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC 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).
Review of the file shows that you were admitted on January 14, 2020 and discharged on January 21, 2020. You
were asked to pay a $375 copayment per day from January 14, 2020 through January 18, 2020, days 1-5 of
your inpatient stay. There were no copayment charges from January 19, 2020, day 6 of your inpatient hospital
care until your day of discharge January 21, 2020. Per your contract there is a $375 copayment per day required
for days 1-5. 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 from January 14,
2020 through January 21, 2020 provided by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for resin-based composite - two surfaces,
posterior (D2392) provided February 19, 2020.
You asked the Plan to waive the coinsurance for the dental services. You say that you feel that the information
that was provided at the time you signed up is misleading. It does not indicate stipulations that must be met in
order for coverage. The Plan denied your request. The Plan says this claim was processed correctly per the plan
benefits.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay $100 deductible on all services except diagnostic, preventive and basic
services and 50% for minor restorative services -fillings and crown repair.
You have been asked to pay $169.50 for the dental services. The service falls within the Dental 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 coinsurance for resin-based composite - two surfaces,
posterior (D2392) provided February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 28, 2019 through January 1, 2020. You asked the Plan to waive the copayment for inpatient hospital care. You say that the extra day spent in the hospital was not necessary. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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). Review of the file shows that you were admitted on December 28, 2019 and discharged on January 1, 2020. You were asked to pay a $375 copayment per day from December 28, 2019 through December 31, 2019, days 1-4 of your inpatient hospital care. You were discharged on January 1, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $375 copayment per day required for days 1-4. 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 from December 28, 2019 through January 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the treating physician did not describe the nature and history of the abdominal pain nor try to rule out simpler diagnoses such as medication side effects, constipation, or hernia, for example, prior to considering advanced imaging. There was no evidence of having completed an x-ray or ultrasound. There was only mild tenderness on examination. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the abdomen and pelvis (74177).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 13, 2019 to May
15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this should be covered because the
treating physician determined inpatient admission was appropriate. The Plan denied your request. The Plan
says that inpatient care was not 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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the emergency department on May 13, 2019 with a fever of 100.3 that
improved to 99.4. She had lab testing, repeat urine testing, and a chest x-ray. She was started on antibiotics and
admitted. Her condition stabilized and improved and she was discharged home on May 15, 2019 when
considered medically stable. The review has determined that the record showed that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 13, 2019 to May 15, 2019.
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 pay for transcutaneous electrical nerve stimulation (tens) device
(E0730) provided November 1, 2019.
You asked the Plan to pay for the TENS device. You say that you have included the letter of medical necessity
for review of this claim and request that this claim be sent back for reprocessing. The Plan denied your request.
The Plan says experimental or investigation services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for
transcutaneous electrical nerve stimulation (tens) device (E0730) provided November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transports provided on January 26, 2020 and January 31, 2020. 
 
You asked the Plan to waive the copayments for the ambulance transports. You say that you should not have to pay more than 20% for these services. The Plan denied your request. The Plan says that the claims processed 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 $210 copayment for covered one-way ground ambulance services.  
 
You have been asked to pay a $210 copayment for the ambulance transports. The ambulance transports fall within the covered one-way ground 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 copayments for the ambulance transports provided on January 26, 2020 and January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on January 15, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for an office visit provided on January 30, 2020.
You asked the Plan to waive the coinsurance for the office visit. You say that you would like reconsideration because you were told that these services would not have a copayment. The Plan denied your request. The Plan says that this claim processed appropriately according to the structure of your plan benefit.
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 does not say in clear and accurate terms how much you should expect to pay for physician services. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% coinsurance for physician services. The Plan contract does not clearly say how much enrollees must pay for physician services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for an office visit provided on January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied
your request. The Plan says coverage criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that CGM's are covered when an enrollee injects
insulin more than three times daily.
We looked at the file and Medicare rules. The record shows the enrollee does not inject insulin three times
daily. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care equipment (A7000, A6550, E2402) provided January 8 to February 1, 2020.
You asked the Plan to waive the coinsurance for the wound care equipment. You say that your maximum out-of-pocket was met in 2019 and the procedure that caused you to need these items was in 2019 so the coinsurance should be waived. The Plan denied your request. The Plan says the items were provided in 2020 and the correct cost sharing was 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 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the wound care equipment. The wound care equipment falls within the Durable Medical Equipment 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 wound care equipment (A7000, A6550, E2402) provided January 8 to February 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for TENS unit with accessories (CPT code E0730, A4556 and
A4630) provided on November 28, 2019 by an out-of-network provider.
You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the records sent by your doctor do not show that you are
enrolled in a clinical study for this special device.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The records sent by your doctor do
not show that you are enrolled in a clinical study for this special device. Therefore, we decided that the Plan
does not have to pay for TENS unit with accessories (CPT code E0730, A4556 and A4630) provided on
November 28, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve these services. You say that the SBRT is needed to help the enrollee with
treatment. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that SBRT 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 enrollee has non-small cell lung
cancer with left adrenal metastases. The entire tumor burden cannot be encompassed in this enrollee with
widespread disease. The Medicare criteria for coverage are not met and the requested SBRT is 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 stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core, in addition to crown, tooth
19 (D2954).
You asked the Plan to pre-approve the dental services. You say that the enrollee is in pain and you request
approval of the procedure that is medically necessary. The Plan denied your request. The Plan says this service
is only covered when a root canal has been done on the tooth. There is no history of a root canal on tooth 19
therefore 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. The Plan covers the dental
services 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 dental services. Our reviewer says
that this requested service does not meet the criteria. Our physician reviewer found the tooth had been prepared
for a crown and temporized. After the initial preparation, the tooth became symptomatic and was treatment
planned for root canal therapy. There has been no clinical note or x-ray supplied showing the post-treatment
condition of #19 following a root canal treatment. Plan criteria for crowns following endodontic treatment
provides that "A request for a crown following root canal therapy must meet the following criteria - Request
should include a dated post-endodontic radiograph. - Tooth should be filled sufficiently close to the
radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the
canal that limits the ability to fill the canal to the apex. - The filling must be properly condensed/obturated.
Filling material does not extend excessively beyond the pex. " The criteria for a proper endodontic seal/fill
would be applicable to a post placement as well. In fact, a post placement is not possible until root canal
treatment has been performed. As there is no post -treatment radiograph of the endodontic treatment, there can
be no medical necessity found for a post and core. If the treatment is completed then the final x-ray should be
submitted for review
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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve prefabricated post and core, in addition to crown, tooth 19 (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the foot orthotics purchased on January 14, 2020. 
 
You asked the Plan to reimburse you for foot orthotics. You say that you thought the orthotics were authorized. 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 reimburse you for the foot orthotics purchased on January 14, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the tissue exam. We decided that the Plan does not have to waive the cost for the tissue exam. You asked the Plan to waive the cost for the tissue exam. You say that you believe the claims processed incorrectly and should be paid with no member responsibility.The Plan says that you have been charged the correct cost sharing amount.We decided that the Plan has to reduce the cost for the tissue exam. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the tissue exam is considered a pathology and laboratory procedure.The Plan says that you must pay $19.18 for the tissue exam. Based on the plan contract, however, you cannot be asked to pay more than a $10 copayment for the tissue exam. Therefore, we decided that the Plan has to reduce the cost for service from $19.18 to a $10 copayment. We also decided that the Plan does not have to waive the cost for the tissue exam.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 $10 copayment for the tissue exam. Therefore, we decided that the Plan does not have to waive the cost for the tissue exam.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.