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

We decided that the Plan does not have to providesensors for use with an interstitial continuous glucose monitor (A9276).You asked the Plan to providesensors for use with an interstitial continuous glucose monitor (A9276).You say that you have used this brand of home monitor for years.The Plan denied your request. The Plan says non-therapeutic CGMs are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code A9276 is Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system.We find that this brand of CGM is not approved by Medicare. Based on this information, we decided that Medicare rules for coverage of sensors for use with a continuous glucose monitor (A9276)have not been met.Therefore, we decided that the Plan does not have to providesensors for use with an interstitial continuous glucose monitor (A9276).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam.

You asked the Plan to pre-approve Lorazepam. You say that the enrollee uses the drug for anxiety and insomnia.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Lorazepam.

Benefits for Lorazepam may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay fora mammogram (77066 & 77062) provided June 5, 2020.You asked the Plan to pay forthe mammogram. You say that the services were medically necessary.The Plan denied your request. The Plan says the units billed exceeds the allowable amount.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 77066 is 1. You billed 2 units of this code, exceeding the MUE. Additionally, CPT code 77062 is assigned a status code of "I" and is invalidfor Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora mammogram (77066 & 77062) provided June 5, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 29, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says
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 Plan says that the Plan has also determined that these services are not
urgent or emergent, nor were they approved in advance.
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 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 a domiciliary or rest home visit provided on July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDexamethasone.You asked the Plan to pre-approveDexamethasone. The Plan denied your request. The Plan says the drug does not meet Medicare criteria for coverage under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not amongthe types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDexamethasone.Benefits for Dexamethasonemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation (D4912) and fluoride application (D1206) provided.

You asked the Plan to pay for dental codes D4910, D4912 and D1206. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services 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 provided dental services with dental codes D4910, D4912 and D1206 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), gingival irrigation (D4912) and fluoride application (D1206) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism.You asked the Plan to pre-approvea seat lift mechanism. You say that the requested seat lift mechanism is medically reasonable and necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested seat lift mechanism.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer says that the enrollee does not meet criteria for the requested seat lift mechanism. Our physician reviewer found the enrollee is with diagnoses of cervical disc degeneration and cervical spinal stenosis, as well as arthritis. The enrollee walks with a walker, and reports that it is difficult for her to get off any chair. The enrollee is independent in transfers from bed and toilet, and is able to ambulate short distances with a front wheeled walker. The enrollee has degenerative joint disease of the right and left knees. The documentation does not support that the enrollee is completely incapable of standing from any chair in the home.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 seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the pelvis (72197) and MRI of the abdomen
(74183) with and without contrast.
You asked the Plan to pre-approve an MRI of the pelvis (72197) and MRI of the abdomen (74183) with and
without contrast. You say that the requested MRI of the pelvis (72197) and MRI of the abdomen (74183) with
and without contrast are medically necessary. The Plan denied your request. The Plan says the requested MRI
of the pelvis (72197) and MRI of the abdomen (74183) with and without contrast are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the pelvis (72197) and MRI
of the abdomen (74183) with and without contrast. Our reviewer says that the requested MRI of the pelvis
(72197) and MRI of the abdomen (74183) with and without contrast are not medically necessary. Our
physician reviewer found the enrollee is with low grade bladder cancer. Per NCCN guidelines, bladder ca
6.2020 page BL-A 1/5 MRI of the pelvis is allowed for sessile or high grade tumors. In this case, the enrollee
has a low grade tumor and neither the MRI of the pelvis nor MRI of the abdomen are 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 an MRI of the pelvis (72197) and MRI of the abdomen (74183) with and
without contrast have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI
of the pelvis (72197) and MRI of the abdomen (74183) with and without contrast.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forMohs micrographic technique provided on August 26, 2020.You asked the Plan to waive the copayment forMohs micrographic technique. You say that you disagree with the surgery 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 outpatient surgery,including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $350 copayment for Mohs micrographic technique. Mohs micrographic technique falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forMohs micrographic technique provided on August 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 3, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan
says that the correct copayment has applied per your contract with the Plan.
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 $155
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound on
August 3, 2020. You have been asked to pay $137.16 for the ultrasound, which is less than the contracted $155
copayment amount. The ultrasound 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 ultrasound provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2750) for tooth # 31.You asked the Plan to pre-approvethe dental service. You say that the enrollee needs the crown.The Plan denied your request. The Plan says crowns are not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat 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-approvea crown (D2750) for tooth # 31.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepain management services (62323) to be provided by an out of network provider.You asked the Plan to pre-approvethe pain management services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are non-emergent. There are network providers available who 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-approvecare 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 services.Therefore, we decided that the Plan does not have to pre-approvepain management services (62323) to be provided by an out of network provider
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who takethem. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are:1. blood-clotting factors; 2. drugs used in immunosuppressive therapy;3. erythropoietin for dialysis patients; 4. osteoporosisdrugs for certain homebound patients;5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment.You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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 the enrollee has pronation of feet and diabetes.The Plan denied your request. The Plan says coverage criteria have not been met.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

The records do not show that the enrollee suffers from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says this service is not a covered benefit under your policy.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7240).
You asked the Plan to pre-approve the removal of impacted tooth. You say that this service is medically
necessary for your condition. The Plan denied your request. The Plan says this service is not covered under the
member's benefit package.
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 the
removal of impacted tooth (D7240).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance forthe braces provided on December 13, 2019.You asked the Plan to waive the coinsurance forthe braces. You say that you were told that the Plan would cover your braces at 100% and you would have a $0 cost share amount.The Plan denied your request. The Plan says that you received durable medical equipment on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for Durable medical equipment in that the contract does not clarify what is considered High Cost Durable medical equipment versus Low Cost Durable medical equipment. We looked at your contract with the Plan. The contract says enrollees must pay a 20% coinsurance for High Cost Durable Medical Equipment and $0 for Low Cost Durable Medical Equipment. However, there is nothing in the contract or the case file provided by the Plan showing that enrollees would know what durable medical equipment is considered High Cost and what durable medical equipment is considered Low Cost. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the coinsurance forthe bracesprovided on December 13, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvefacet joint injections (64493).You asked the Plan to pre-approvethe facet joint injections. You say that the facet joint injection is medically necessary.The Plan denied your request. The Plan says that previous injections did not provide sustained pain relief.The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when medically necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the facet joint injections. Our reviewer says that the requested facet joint injections are medically necessary. Our physician reviewer found the enrollee had a prior Epidural Steroid injection that was not effective and NOT a facet injection. The injection is appropriate.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 facet joint injections have been met.Therefore, we decided that the Plan has to pre-approvefacet joint injections (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean overdenture (D5865).You asked the Plan to pre-approvethe overdenture. You say that the enrollee needs this overdenture.The Plan denied your request. The Plan says this service 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-approvean overdenture (D5865)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIRF admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets CMS criteria for an IRF admission. The Plan denied your request. The Plan says basedon Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld.The enrollee does not require the intensity of services provided at an IRF.Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS, LTC).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRFadmission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by the out-of-network provider.You asked the Plan to pre-approve dialysis. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services. Therefore, we decided that the Plan does not have to pre-approve dialysis to be provided by the out-of-network provider