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

We decided that the Plan does not have to pre-approve joint surgery and knee arthroscopy for the enrollee.

You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical effectiveness of arthroscopic lavage and arthroscopic debridement for the severe osteoarthritic knee has not been verified by scientifically controlled studies.

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 procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for internal derangement of right and left knee. The treating physician report cites bilateral knee pain. The problem is fluctuating. The symptoms are relieved by injections and pain medicine. Exam of the left knee reveals mild effusion. There is medial and lateral joint line tenderness. There is pain on range of motion, with motion at 0-120. There is persistent knee pain without significant mechanical issues. There is documentation indicating she is not a candidate for an MRI of the knee. However, documentation does not demonstrate objections to other forms of advanced imaging. There is also no supportive documentation indicating there is a ligamentous tear which requires repair. There is no significant indication that the member has had a traumatic injury to the ligaments/menisci of the knee. Therefore, the request for left knee arthroscopic medial or lateral meniscectomy, synovial biopsy and debridement/shaving of articular cartilage would not be considered medically reasonable or 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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve joint surgery and knee arthroscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 13, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges. 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 $350 copayment for ambulance services. 

You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall 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 for ambulance services provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the shipping and handling and sales tax for items purchased.

You asked the Plan to reimburse you for the shipping and handling and sales tax. You say that you would like to be reimbursed. The Plan denied your request. The Plan says these services are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that sales tax and shipping are not separately payable by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shipping and handling and sales tax have not been met. Therefore, we decided that the Plan does not have to reimburse you for the shipping and handling and sales tax for items purchased.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional chiropractic visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says there have been 23 visits so far.

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 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 additional visits Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the only treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be demonstrated by x-ray or by physical examination. Three submitted imaging studies reveal the following: September 15, 2020: lumbar spine x-rays, in comparison to 2016, revealed moderate multilevel degenerative disc and facet changes; and, September 15, 2020: MRI of the lumbar spine, reveals, mainly: moderate bilateral neural foraminal narrowing at L1-2, moderate bilateral recess narrowing and severe right and moderate left foraminal narrowing at L3-4, severe left lateral recess narrowing at L5-S1, with severe left and moderate right neural foraminal narrowing. These findings do not reveal evidence of a subluxation. The medical submitted chart notes/office visit notes, including September 3, 2020 and September 17, 2020, only reveal positive findings of abnormal plantar reflexes and ankle clonus. The one submitted chiropractic note, dated January 20 2021, Reveals circle the response findings of palpation findings of tenderness and segmental dysfunction at L4-5 and right and left sacroiliac joints. These findings do not reveal evidence of subluxation per Medicare guidelines. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional chiropractic visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of this procedure as the member is not enrolled in a clinical study.

The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets additional criteria. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, Medicare rules say that this service is covered when provided in a clinical study. The documentation provided does not indicate that the member is enrolled in a clinical study at this time. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a CGM. The Plan denied your request. The Plan says criteria for a CGM is not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair.

You asked the Plan to pre-approve a commode chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested commode chair.

The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. 

The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a commode chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for inpatient services.

You asked the Plan to adjust the coinsurance for the inpatient services. You say that you were only in the hospital for one day. The Plan denied your request. The Plan says although the dates of service span three days the hospital only billed 1 unit.

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 10% coinsurance for Inpatient Hospital Care.

You have been asked to pay 10% coinsurance for the inpatient services. The inpatient services fall within the Inpatient Hospital Care benefit category. The record shows you were only billed for one inpatient day. 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 adjust the coinsurance for inpatient services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye injections provided from July 30, 2020, through August 27, 2020.

You asked the Plan to waive the copayment for the eye injections. You say that both visits were for injections in your right eye and you cannot understand how the $279.66 copayment was determined. The Plan denied your request. The Plan says the claims were 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 show that you received the eye injections from July 30, 2020, through August 27, 2020. The injections fall under the outpatient surgery category. The Medicare-allowed amount for the services is less than the set $295 copayment per date of service; therefore, you have been asked to pay the lesser amount of $279.66 per date of service for the eye injections. The health plan contract says that enrollees must pay a $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 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 eye injections provided from July 30, 2020, through August 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from October 8, 2020, through November 4, 2020.

You asked the Plan to waive the copayment for skilled nursing facility services. You say that you were not informed about the copayment. The Plan denied your request. The Plan says the copayment was 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 $160 per day for days 21-44 for skilled nursing facility care. 

You have been asked to pay $160 per day for days 21-44 for skilled nursing facility services. The services at issue fall within the skilled nursing facility 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 skilled nursing facility services provided from October 8, 2020, through November 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear diagnostic thyroid imaging services (78014, A9516).

You asked the Plan to waive the copayment for nuclear imaging services. You say that you did not know there would be a copay and would not have had the service if you had realized there was a copay. The Plan denied your request. The Plan says the contract states there is a $175 copayment for nuclear medicine diagnostic tests.

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 $175 copayment for nuclear medicine radiological services.

You have been asked to pay a $175 copayment for nuclear imaging services. Nuclear imaging services fall within the nuclear medicine radiological 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 for nuclear diagnostic thyroid imaging services (78014, A9516).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Radiofrequency Ablation procedure (64625).

You asked the Plan to pre-approve the Radiofrequency Ablation procedure. You say that the services are 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 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 Radiofrequency Ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the reviewed literature, Radiofrequency ablation used for sacro-iliac joint pain is considered investigational whether performed using traditional, cooled, or pulsed radiofrequency. Investigational services are not covered. 

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 Radiofrequency Ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Radiofrequency Ablation procedure (64625).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says an invalid CPT code was 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 the lab tests are not supported in the medical record. Specifically, per Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), this service should be reported using CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found in this case, there are no exigent circumstances that require emergent or urgent circumstances. The provided records do not indicate a need that cannot be met the plan providers. The plan has provided a list of in network providers that have not been seen by the enrollee. Therefore, the provision of care by an out-of-network provider cannot be recommended 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 the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on October 6, 2020.

You asked the Plan to pay for the dental item. You say that the denture should be covered. You say that you were in a motorcycle accident where you were hospitalized. You say that your dentures were completely shattered and you needed new ones. You also say that other providers wanted to take 3 to 4 months to make the dentures and this provider would get them done in 4 weeks. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental items and services that you receive out of network are 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 when provided out of network. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5225, D5226, D1208).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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. 

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 pre-approve dental services (D5225, D5226, D1208).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).

You asked the Plan to pre-approve the dentures. You say that this should be paid for. The Plan denied your request. The Plan says the benefit limit 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. The Plan covers dentures once every five years.

Dentures were last received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of service.

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 G0483 is not supported in the medical record. Specifically, the claim form shows the specimen was obtained at Place of Service 81 (laboratory), however the records show the specimen was obtained in the office setting (Place of Service 11). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483).