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

We decided that the Plan does not have to waive the copayment for an MRI provided on July 12, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you were advised that the Plan covered the services. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for each radiological diagnostic service. The enrollee has been asked to pay a $100 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BCR-ABL1 testing rendered to on September 10, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that BCR-ABL1 testing performed as a panel must be billed with single code 81479. We looked at the file and Medicare rules. The file shows that the claim for these services was billed with multiple codes and not the required single code of 81479. 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 pay for the BCR-ABL1 testing rendered to on September 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the EMS services were medically necessary because you were having a hypoglycemia diabetic situation. You were at work when you became unresponsive and EMS was called. The responders tested your blood sugar and treated you with an IV. After you were stabilized, you were able to speak with the EMS responders and they wanted to take you to the hospital but you declined. You say that you felt it was unnecessary and would have incurred a hefty medical bill which you say you could not afford. You say that the emergency services should be partially covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous vertebral augmentation.You asked the Plan to pre-approvethe procedure. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that the above criteria must be met in order for percutaneous vertebral augmentation to be considered for coverage.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 procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that the records did not suggest moderate to severe pain (as required by the LCD).Furthermore, there is not an indication of a multidisciplinary team consensus for the performance of this procedure. The criteria for coverage of this procedure 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 the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvepercutaneous vertebral augmentation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist, hand orthosis (L3916) provided on November 1, 2018.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the billed supply code cannot be verified
The Plan must follow Medicare rules. The rules say that items and services that are not medically necessary are not covered. The documentation submitted did not indicate the provider discussed the need for the billed supply code. Therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for wrist, hand orthosis (L3916) provided on November 1, 2018.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve BRAF genetic testing.You asked the Plan to pre-approveBRAF testing. You say that this test is part of the National Comprehensive Cancer Network (NCCN) guidelines for the enrollee's treatment.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the information submitted does not show how this testing will change management of the enrollee's condition.The Plan follows Medicare rules. Medicare rules say that BRAF genetic testing is part of the stepped approach that physician/pathologists are expected to follow for Lynch Syndrome testing.We askedour 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 BRAF testing. Our reviewer says that the enrollee meets the Medicare criteria for therequested BRAF genetic testing. Our physician reviewer found the enrollee has newly diagnosed metastatic colon cancer. There is no evidence that he has received prior genetic testing. National Comprehensive Cancer Network (NCCN) guidelines include treatment options that would be based on the results of BRAF testing. Therefore, this testing is medically necessary.We looked at this physician's review, the file, and Medicare rules. The results of this testing may affect treatment options for the enrollee's condition, and this test is covered as part of Medicare's stepped approach to Lynch Syndrome testing. Based on this information, we decided that Medicare rules for coverage of BRAF testing have not been met.Therefore, we decided that the Plan has to pre-approveBRAF genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen for the enrollee.
You asked the Plan to pre-approve Privigen. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not compendia supported.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Privigen. Our reviewer says that Privigen is not medically reasonable and necessary for the enrollee in this case. The enrollee has a primary diagnosis of small fiber neuropathy for which she has been prescribed IVIG. IVIG is not FDA approved for use in this condition/diagnosis. Nor is the diagnosis supported for use within the Medicare accepted Compendia. The published literature on the use of IVIG in this condition is largely limited to case reports and/or case series that involve patients with other underlying autoimmune conditions (which are not applicable to this case). There otherwise remains a need for quality prospective trials to be completed to formally evaluate the use of IVIG in small fiber neuropathy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Privigen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).You asked the Plan to pre-approvethe dental item. You say that you received a denial for the authorization of dentures. You say that you have a $1,500 benefit coverage for this year and that dentures are covered. You say that you received a partial denture in 2017 but it is not a good fit for you. You also say that you do not have any teeth and your gums are rotting and you are a diabetic.The Plan denied your request. The Plansays dentures are covered once every 5 years. The Plan also says that the frequency limit has 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 and complete dentures are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for a lower partial denture that you received on August 21, 2017.Therefore, we decided that the Plan does not have to pre-approvea complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 1, 2019 to November 2, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted for less than 24 hours and disagree with 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 $180 copayment for each day for days 1-7 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from November 1, 2019 to November 2, 2019. Therefore, you are responsible to pay the $180 copayment. You have been asked to pay a $180 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided from November 1, 2019 to November 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on March 18, 2018.You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the information received does not show that the member had a skilled nursing need or that the nursing visit was medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the documentation submitted did not include any medical records to determine if the home health services were medically necessary. Therefore, we decided that the Plan does not have to pay for home health services provided on March 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on November 8, 2019.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you cannot afford your hospital visits for your infusions and injections. You say you are only receiving Social Security. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% of the total cost for Medicare-covered chemotherapy drugs and other Medicare-covered Part B prescription drugs. You have been asked to pay a total amount of $1,058.98 which is 20% of the allowed amount for the Part B injections. The total allowed amount is $5,294.72. ($5,294.72 x 20% = $1,058.98). The Part B injections fall within the "Medicare Part B prescription drugs" 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 Part B injections provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the periapical x-ray (D0220), the bitewing x-ray (D0270), and the panoramic x-ray (D0330) provided from October 7, 2019 to October 15, 2019.You asked the Plan to pay forthe dental services. You say that your dentures were not fitting properly after several adjustments and what appears to be a poorly done alveoloplasty on August 2, 2019. You say that you needed the x-rays to ensure there were no teeth under your gums.The Plan denied your request. The Plan says panoramic x-rays are covered once every 3 years. The Plan says that the frequency limit has been exceeded. The Plan says that the maximum annual benefit of $1,000 has been exhausted prior to receiving these services.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 panoramic x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the panoramic x-ray that you received on May 16, 2019. Additionally, the annual maximum benefit of $1,000 has been exhausted prior to receiving these services. Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the periapical x-ray (D0220), the bitewing x-ray (D0270), and the panoramic x-ray (D0330) provided from October 7, 2019 to October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on November 12, 2019.You asked the Plan to pay forthe dental service. You say that you require periodontal maintenance 3 time per year in order to keep from losing teeth and possibly needing denture or other procedures. You say that the plan only covers 2 cleanings per year and therefore you have to pay for 1 cleaning every year. You also say that you are on a fixed income and have a very tight budget.The Plan denied your request. The Plan says 2 cleanings per year are covered. The Plan also says that the benefit limit has been exceeded.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 periodontal maintenance is a covered service, the benefit limit of up to 2 per year has been exceeded. The record shows that the Plan paid for the periodontal maintenance that you received on January 9, 2019 and July 19, 2019.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on November 12, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care provided on November 5, 2019.
You asked the Plan to pay for the hospital care. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital care provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on October 15, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should consider the claim to be enrollee liability. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee, complaining of constipation, was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services provided by  on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that failure to undergo therapy would result in inadequate treatment. The Plan denied your request. The Plan says an in-network provider can provide the requested 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to the enrollee on April 2, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We looked at the file and Medicare rules. The file does not show that the services were certified by a doctor. There are no records to support that the services were medically necessary for the enrollee. 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 pay forthe home health services rendered to the enrollee on April 2, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing on October 29, 2019.
You asked the Plan to pay for testing. You say that this testing was medically necessary and the treating physician did not have the ability to order this testing from another provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because there were no records provided to show information about the enrollee's condition, why tissue-based genetics could not be done, and how the testing would affect treatment and management of the enrollee.
The Plan must follow Medicare rules. Medicare rules say that testing is only covered by Medicare for enrollee's diagnosed with advanced non-small cell lung cancer (NSCLC) who meet certain criteria. We looked at the file and Medicare rules. The documentation does not show that this testing was ordered for a diagnosis of advanced non-small cell lung cancer. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a low dose CT Scan for lung cancer screening (G0297) provided on October 25, 2019.You asked the Plan to pay for the low does CT Scan. You say that you would like reconsideration because the member's condition proved the medical necessity for the service. The Plan denied your request. The Plan says services related to screening for lung cancer with low dose computed tomography are only covered for certain diagnoses indicating nicotine dependence.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 G0297 is not supported in the record. Specifically, per Medicare, this service is only covered for certain diagnoses. The diagnosis code submitted on this claim is not approved per CMS. Based on this information, we decided that Medicare rules for coverage of the low does CT Scan have not been met. Therefore, we decided that the Plan does not have to pay for a low dose CT Scan for lung cancer screening (G0297) provided on October 25, 2019.