Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medtronic Guardian continuous glucose monitoring sensors.You asked the Plan to pre-approve Medtronic Guardian sensors. You say that the enrollee is using a Guardian CGM and needs the sensors.The Plan denied your request. The Plan says Medicare does not cover non-therapeutic CGMs and supplies.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. Code A9276 is Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system. Based on this information, we decided that Medicare rules for coverage of Medtronic Guardian sensors have not been met. The Plan does not have to provide sensors for a non-therapeutic continuous glucose monitoring system.Therefore, we decided that the Plan does not have to pre-approve Medtronic Guardian continuous glucose monitoring sensors.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 11, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the provider is notin-network and there is no authorization on file.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 nota network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on February 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nurse visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not need wound care or injectable medications.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 visits. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found there are no identified
unaddressed medical issues or skin care issues. You are alert and fully oriented and would be expected to be
able to self-monitor her medical conditions and administer medications. When evaluated there were no
abnormal physical examination findings recorded.
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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve home health nurse visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under code
0005U.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this test is not covered by Medicare. The Plan states that each test has a unique code
assigned to it. This is called a procedure code. The requested code is not a covered benefit by Medicare.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of genetic testing.
Medicare does not cover code 0005U for the indications billed. Medicare rules for coverage of this service
have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the
enrollee and billed under code 0005U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased August 5, 2019.
You asked the Plan to pay for the hearing aids. You say that you attempted to get hearing aids from the facility but had to return them because they did not fit properly. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation/general anesthesia coded as D9222/D9223 provided September 9, 2019 to September 23, 2019.
You asked the Plan to pay for deep sedation/general anesthesia. You say that you have a payment of $414 that you were not aware of having to pay but you did pay it. You followed all processes to get your procedures. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 pay for deep sedation/general anesthesia coded as D9222/D9223 provided September 9, 2019 to September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an anesthetic agent injection (64520).
You asked the Plan to pre-approve the injection. You say that this injection is medically necessary. The Plan denied your request. The Plan says the member has not had any physical therapy.
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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found records do not indicate aggressive non-invasive measures have been exhausted, and there is also a lack of high-quality medical science backing this particular intervention. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an anesthetic agent injection (64520).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on October 16, 2019.You asked the Plan to waive the copayment forthe office visit. You say that this should not have been an office visit. You say that it should be free.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for a specialist visit. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for pain in the right knee. 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 forthe office visit provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric evaluation provided on September 11, 2019.
You asked the Plan to waive the copayment for the psychiatric evaluation. You say that you did not ask for the service and there was not a need for your doctor to order it. You say you did not know you were being evaluated. 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 a $30 copayment for each Medicare-covered individual or group therapy visit. You have been asked to pay a $30 copayment for the psychiatric evaluation. The psychiatric evaluation falls within the "Outpatient mental health 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 the psychiatric evaluation provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Flexitouch pneumatic compression device and appliances from the provider.
You asked the Plan to provide a pneumatic compression device (E0653) and appliances (E0667). You say that the enrollee has used E0651 but it did not manage the edema and caused pain and discomfort. The Plan denied your request. The Plan says there is no notes indicating the enrollee has leg swelling with fluid into the abdomen, chest, or trunk, and the provider is out-of-network.
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 has lymphedema into the trunk, chest, or abdomen or has 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. Also, Tactile Medical is an out-of-network provider. Therefore, we decided that the Plan does not have to provide a Flexitouch pneumatic compression device and appliances from the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass lenses provided on September 30, 2019.
You asked the Plan to pay for the eyeglass lenses. The Plan denied your request. The Plan says there is no routine eyewear coverage under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. We looked at the file and the rules. The file shows there is not a routine eyewear benefit under the enrollee's plan. The services you asked the Plan to pay for are considered routine eyewear. Therefore, we decided that the Plan does not have to pay for eyeglass lenses provided on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging at the in-network benefit level.
You asked the Plan to pre-approve the services at the in-network benefit level. The Plan denied your request.
The Plan says the services are available in-network.
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 50% coinsurance for out-of-network nuclear medicine services.
The services in question are available from in-network providers, which means the plan is not required to
adjust the cost sharing for out-of-network services to the in-network benefit level. The enrollee is required to
pay a 50% coinsurance for the nuclear medicine services. 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 preapprove
myocardial perfusion imaging at the in-network benefit level.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 10, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that the transport was not by your request and you had no choice in the matter. 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 $225 copayment for ambulance services.
You have been asked to pay a $225 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 10, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for discitis/osteomyelitis and pneumonia/empyema. The enrollee has undergone surgical drainage of her spinal infection and tube drainage of her lung infection. The enrollee continues to receive a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reimburse you for the digital images and core build up. We decided that the Plan does not have to reimburse you for the oral evaluation and the root canal.
You asked the Plan to reimburse you for the digital images and core build up. You say that this was an emergency procedure. You say that you were in extreme pain and did not have time to research an in network dentist so you went to see your dentist of 25 years. You say that the dentist recommended an immediate root canal for the abscess and extreme pain. You also say that you could not eat or drink fluids of any temperature without pain. The Plan denied your request. The Plan says there is a $35 deductible per year for dental services.
The Plan says that digital images, 2 or more, is not listed as a covered service. The Plan also says root canals and core build up are not covered services.
We decided that the Plan has to reimburse you for the digital images and core build up.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The "list of dental codes" that are linked on page 100 of the Evidence of Coverage do not show a list of the 2019 dental codes that are covered, only those covered for 2020. Without this information, we are unable to determine if the denied services were actually not covered. Therefore, we decided that the Plan has to reimburse you for the digital images and core build up.
We also decided that the Plan does not have to reimburse you for the oral evaluation and the root canal.
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, dental services are subject to a $35 deductible. The record shows that the deductible was applied to the oral evaluation, as a result only $2.40 was paid by the Plan. Additionally, the root canal is not among those covered under this benefit. The Evidence of Coverage does not specifically list endodontic services as covered. Therefore, we decided that the Plan does not have to reimburse you for the oral evaluation and the root canal.
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: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax with contrast material (71260).
You asked the Plan to pre-approve a CT scan of the thorax. You say that this is necessary to ensure that there has been no disease progression. The Plan denied your request. The Plan says that a low-dose CT scan would be more appropriate.
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 a CT scan of the thorax. Our reviewer says that the requested CT is medically necessary. Our physician reviewer found guidelines show that surveillance scans can be done for up to 5 years. The records support that this CT is necessary as the final chest CT, and subsequent testing should be annual low-dose CT scans. 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 CT scan of the thorax have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax with contrast material (71260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on September 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for out-of-network podiatry services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 has network providers available who can provide 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 the podiatry services provided on September 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management injections (64635 and 64636).
You asked the Plan to pre-approve the injections. You say that this service is medically necessary for the
treatment of the member's condition. The Plan denied your request. The Plan says the clinical information
provided does not describe dual successful median branch blocks.
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 injections. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found per the LCD, dual diagnostic medical branch blocks are required. The record indicates only one
set of blocks has been performed. At this point, the request is premature.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve pain management injections (64635 and 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ophthalmology visit (99204) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the ophthalmology visit. You say that the in-network provider cannot provide the service at issue.The Plan denied your request. The Plan says there are in-network providers that can render the service at issue, including medical center. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe Ophthalmology visit (99204) to be provided by an out of network (OON) provider.