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

We decided that the Plan does not have to pre-approve palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) (CPT code 42145), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says there are no conditions in the enrollee's medical record that will allow for coverage of this service.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a surgical approach for the treatment of obstructive sleep apnea (OSA) is primarily reserved for patients with severe, obstructing lesions of the upper airway who have failed positive airway pressure therapy and/or an oral device. Surgical treatment appears to be most effective in patients who have OSA due to a severe, surgically correctable, obstructing lesion of the upper airway such as tonsillar hypertrophy, adenoid hypertrophy, or craniofacial abnormalities. The documentation does not support the enrollee in this case has failed treatment with continuous positive airway pressure therapy (CPAP), and the enrollee's physical exam does not demonstrate a severe obstructing lesion of the upper airway.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) (CPT code 42145), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that the enrollee needs this item. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. The item at issue is not medical in nature. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) your received on September 16, 2020 at an outpatient hospital facility.

You asked the Plan to waive the copayment for the TTE. You say that you cannot afford this copayment. 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 $10 copayment for outpatient diagnostic tests. 

You have been asked to pay a $10 copayment for the TTE. The TTE 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 for the transthoracic echocardiography (TTE) your received on September 16, 2020 at an outpatient hospital facility.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you feel there is confusion 
regarding what is requested. You want this resolved so you can get the imaging you need. The Plan denied your request. The Plan says a diagnostic CT scan was approved and covered, as well as an abdominal CT scan. 
There is no need for a low-dose CT scan when a standard scan was already done. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the above described criteria.  
 
We reviewed the file and the Medicare rules. We find that you are not asymptomatic as this imaging was 
requested due to unexplained weight loss with chronic cough. Therefore, we decided that the Plan does not 
have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the portable ventilator is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found the record indicates 
does not provide a sufficient reason why a BiPAP machine that can accommodate the prescribed settings would 
not be appropriate for the enrollee. does not provide a sufficient reason why a BiPAP machine that can accommodate the prescribed settings would not be appropriate for the enrollee. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the oncology office visit you had on
February 13, 2021, the lab services you had on February 19, 2021, and February 24, 2021, and the magnetic
resonance imaging (MRI) of the pelvis you had on March 3, 2021, at an outpatient hospital facility.

You asked the Plan to waive the copayments for the specialist visit, lab services, and MRI. You say that you
are not financially able to pay these copayments. The Plan denied your request. The Plan says you were
charged these copayments correctly. The Plan says that for the lab services on February 19, 2021, since the
allowed amount for this service ($3.17) is less than your copayment obligation, you are responsible for the full
allowed amount for this service.

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 $40
copayment for visits with a specialist, a $5 copayment for lab services, and a $200 copayment for diagnostic
radiology services at an outpatient hospital facility.

You have been asked to pay a $40 copayment for the specialist visit, a $5 copayment for each of the lab
services, and a $200 copayment for the MRI. 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
oncology office visit you had on February 13, 2021, the lab services you had on February 19, 2021, and
February 24, 2021, and the magnetic resonance imaging (MRI) of the pelvis you had on March 3, 2021, at an
outpatient hospital facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing or skilled therapy services daily. The enrollee does not require the services provided on an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are necessary for low back pain, foot pain, toenail itching and discoloration. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with severe diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

The medical records show you do not suffer from severe 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 orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformoterol.

You asked the Plan to pre-approve Arformoterol. You say that this is medically necessary for you. The Plan denied your request. The Plan says that you have not tried and failed the preferred step therapy drug.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Arformoterol. Our reviewer says that Arformoterol is not medically reasonable and necessary. You have not tried and failed Perforomist. There is no documentation provided indicating that Perforomist would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Arformoterol. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arformoterol have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the end stage renal disease (ESRD) services provided from January 3, 2021, to January 29, 2021.
You asked the Plan to pay for the ESRD services. The Plan denied your request. The Plan says that the services were billed incorrectly.
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. In this case, code J0606 was billed with the appropriate -AX modifier. The Plan has not provider documentation supporting its denial of the ESRD services at issue in this case. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the end stage renal disease (ESRD) services provided from January 3, 2021, to January 29, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography.

You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested transthoracic
echocardiography is medically necessary. The Plan denied your request. The Plan says the enrollee does not
meet criteria for the requested transthoracic echocardiography.

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 a transthoracic echocardiography. Our
reviewer says that the enrollee does not meet criteria for the requested transthoracic echocardiography. Our
physician reviewer found the enrollee is with a history of mild left ventricular dysfunction since 2008. A
limited echocardiogram on 11/18/20 was notable for global hypokinesis, with a mildly reduced ejection
fraction (45 - 50%). Mild mitral valve regurgitation and moderate aortic valve regurgitation were documented.
The enrollee was seen in the cardiology clinic on 5/7/21. The enrollee denied symptoms in a review of systems.
The physical exam was notable for systolic and diastolic murmurs. The plan included a repeat echocardiogram
at her next upcoming appointment.

The LCD L34338 states, "Absent acute intervention, or a discrete change in otherwise stable clinical signs and
symptoms, it is not medically necessary to repeat these examinations more frequently than annually." In this
case, the requested transthoracic echocardiography is not 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 a transthoracic echocardiography have not been met. Therefore, we decided that
the Plan does not have to pre-approve a transthoracic echocardiography.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on April 16, 2021.

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 the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 23, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. You 
say that you go to Arizona during the winter months. The Plan denied your request. The Plan says prior 
authorization was not obtained by the member's primary care physician. 
 
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 an office visit provided on March 23, 2021 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 an eye examination provided on  
March 31, 2021. 
 
You asked the Plan to waive the copayment for the eye examination. The Plan denied your request. The Plan 
says the claim 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 $20 
copayment for Vision Care.  
 
You have been asked to pay a $20 copayment for the eye examination. The eye examination falls within the 
Vision 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 eye examination 
provided on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray you had on May 19, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you believe this copayment should be
waived because the only reason you needed this x-ray was due to being post-operative. The Plan denied your
request. The Plan says you were charged this copayment correctly. The Plan says that x-rays are separately
payable following surgery. The Plan also says that because the allowed amount for the x-ray (34.62) is less
than your copayment obligation, you are responsible for the full allowed 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 $55
copayment for x-rays and ultrasounds.
You have been asked to pay a $55 copayment for the x-ray. Medicare rules explicitly state that radiology
services performed following surgery are not part of the global surgical package payment and separate cost
sharing may apply. 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 x-ray you had on May 19,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cub II Elliptical.

You asked the Plan to pre-approve exercise equipment. You say that this equipment is medically necessary. The Plan denied your request. The Plan says exercise equipment is not covered by Medicare.

The Plan must follow Medicare rules. The rules say exercise equipment is not covered. This equipment is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Cub II Elliptical.