Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an intrathecal medication trial.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this request is for an intrathecal medication trial using Hydromorphone, epidurally administered. This is not an epidural steroid injection. This procedure is a standard of care and is medically reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-approve an intrathecal medication trial.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0003).

You asked the Plan to pre-approve the wheelchair. You say that you have an amputated left leg, weakness, and restless leg syndrome. The Plan denied your request. The Plan says this is not medically necessary.

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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is not clear that your mobility limitation significantly impairs your ability to participate in one or more mobility-related activities of daily living, such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal that your mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted walker. The documentation does not reveal that the use of the requested wheelchair will significantly improve your mobility-related activities of daily living. The documentation does not reveal that you are unable to self-propel in a standard wheelchair 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 the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the outpatient office visit (99211) continuous glucose monitoring (95250) provided December 7, 2020.

You asked the Plan to waive the co-payment for the office visit. You say that you feel like they are overcharging for the care that you received on that day. The Plan denied your request. The Plan says this claim was processed and the correct co-payment was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 for covered specialist services.

You have been asked to pay $45 for the office visit. The office visit falls within the Physician/practitioner services, including doctor's office visits 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 co-payment for the outpatient office visit (99211) continuous glucose monitoring (95250) provided December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), and unspecified preventive service (D1999) provided on December 9, 2020.
You asked the Plan to pay for the dental services. You say that you paid an extra $18 to have this service provided. You say that you went to the office for a cleaning and preventive visit. You say that you feel that since you are paying extra for dental services every month, this service should be covered. The Plan denied your request. The Plan says 2 periodic oral exams are covered per calendar year. The Plan says that 2 prophylaxes are covered per calendar year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that unspecified preventive service is not listed as a covered service.
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 periodic oral exam and prophylaxis are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on January 8, 2020, and June 3, 2020. Additionally, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120), prophylaxis (D1110), and unspecified preventive service (D1999) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and testing services rendered on September 24, 2020.
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 deductible was applied correctly and the testing is not covered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,500 yearly deductible for your covered medical services. The item or service you asked the Plan to pay for falls within the out-of-network specialist's office services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the office visit services were received on September 24, 2020. The rules say that a status indicator of T represents a code that is only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.
The provider billed procedure code 94760 (non-invasive ear or pulse oximetry for oxygen saturation). This code has a status indicator of T and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the office visit and testing services rendered on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on August 3, 2020.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a fixed dental bridge (D6740, D6245).
You asked the Plan to pre-approve the fixed bridge. You say that the bridge is medically necessary. The Plan denied your request. The Plan says that a fixed bridge is not medically necessary.
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 a bridge when the services are medically necessary and reasonable. 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 fixed bridge. Our reviewer says that the requested services are medically necessary. Our physician reviewer found a review of the patient's dental record and radiographs indicate the presence of a current fixed bridge in place of tooth #19. Recurrent caries were indicated under the crown abutments of teeth #18 and #20. To properly restore these teeth the crowns would have to be removed and new crowns placed. It is reasonable that since the crowns on teeth #18 and #20 need to be replaced, the pontic on tooth #19 should be replaced as well. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have been met. Therefore, we decided that the Plan has to pre-approve a fixed dental bridge (D6740, D6245).
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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for extractions (D7140, D7120) provided on January 11, 2021.
You asked the Plan to pay for the extractions. You say that these services were necessary. The Plan denied your request. The Plan says that this service is not covered by Medicare or by the Plan's supplemental dental 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. The Plan can cover two oral exams and cleanings and one x-ray per year as long as the member visits a participating dental provider. The Plan denied payment for these extractions because they are not among the services listed as covered under the supplemental dental benefit.
However, additional coverage for preventative and comprehensive dental services, such as extractions, can be provided through the Plan's flex benefit. There is a $400 annual maximum for the purchase of non-Medicare healthcare items under the flex benefit.
We looked at the file and Medicare rules. Based on this information, we decided that the extractions can be covered under the Plan's flex benefit up to $400. Therefore, we decided that the Plan has to pay the $400 maximum allowed by the flex benefit for the extractions (D7140, D7120) provided on January 11, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing care provided from April 15, 2018, to August 29, 2018.
You asked the Plan to pay for the skilled nursing care. You say that the services were rendered appropriately and in good faith. You also say that you would like the timely filing edit overridden and payment made for this claim. The Plan denied your request. The Plan says the claim was submitted to the Plan later than 1 calendar year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the skilled nursing care was not filed until October 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the skilled nursing care provided from April 15, 2018, to August 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an urgent care visit provided on July 31, 2020.

You asked the Plan to waive the co-payment for urgent care visit. You say that you were required to go to this provider to receive a rapid COVID-19 test. The Plan denied your request. The Plan says the co-payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co-payment for urgent care visit. Please note that this co-payment is being applied to the urgent care office visit. The COVID-19 laboratory test you received was covered by the Plan with no cost-share responsibility for you.

You have been asked to pay $50 co-payment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 co-payment for an urgent care visit provided on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found CardioMEMs pressure sensor monitoring can be utilized in previously hospitalized patients with persistent Class III symptoms related to congestive heart failure that have not been responsive to optimally titrated doses of guideline directed medical therapy and oral diuretics. As the etiology of the dyspnea symptoms remains unclear based on the records provided and, in addition, she has not been treated with recommended optimally dosed medical therapy and oral diuretics, she does not meet published criteria or FDA indications for the CardioMEMs device 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion and injection services coded as 96413, 96367, 96377, 96375, J3490, J2469, J1200, J1100, J9043 and J2505 provided September 26, 2019.
You asked the Plan to pay for the infusion and injection services. You say that you had met your annual out of pocket expense of $1900 at the time of the injection. You should have no responsibility after your out of pocket has been met. The Plan denied your request. The Plan says this claim was processed and the correct cost share was applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $2,300.00 maximum out of pocket and 20% coinsurance for Part B covered chemotherapy drugs. The item or service you asked the Plan to pay for falls within the benefit category Medicare part B Prescription drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $2,300.00 maximum out of pocket and 20% coinsurance for Part B covered chemotherapy. The maximum out of pocket was met as of 10/16/2019. This cost sharing is a contractual obligation that had not been met at the time the infusion and injection services was received on September 26, 2019. Therefore, we decided that the Plan does not have to pay for the infusion and injection services coded as 96413, 96367, 96377, 96375, J3490, J2469, J1200, J1100, J9043 and J2505 provided September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GI capsule endoscopy (91110).
You asked the Plan to pre-approve GI capsule endoscopy. You say that the enrollee has iron deficiency and you are requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the submitted documentation does not support that the enrollee meets the criteria for coverage.
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 GI capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available record neither documents iron deficiency nor objective evidence of GI blood loss. Further, her last colonoscopy dates to 2018. Based on available records, the enrollee does not meet medical necessity nor coverage criteria for capsule endoscopy as proposed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GI capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve GI capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Needle electromyography (95870), Central motor evoked potential study (95938), and Continuous intraoperative neurophysiology monitoring (G0453).
You asked the Plan to pay for the neuromonitoring services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the submitted diagnosis code M46.061 is not a covered diagnosis for the procedures.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis code. We find that diagnosis code M46.061 is not a covered diagnosis for these procedures. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for Needle electromyography (95870), Central motor evoked potential study (95938), and Continuous intraoperative neurophysiology monitoring (G0453).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71046) provided on December 8, 2020, by an OON
provider.
You asked the Plan to pay for an OON x-ray. You say that this was medically necessary. The Plan denied your
request. The Plan says this was 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an x-ray (71046) provided on December 8, 2020,
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom-fabricated abutment (D6057) and abutment supported crown (D6058) provided on September 29, 2020.
You asked the Plan to pay for the abutment and supported crown. You say that these services were a more cost-effective option for everyone involved, and therefore should be covered. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 pay for the custom-fabricated abutment (D6057) and abutment supported crown (D6058) provided on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility (IRF) care provided from October 24, 2020, through November 3, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 per day for days 1-5 for inpatient hospital care.

You have been asked to pay $1,625 ($325 x 5 days) for the inpatient rehabilitation provided. 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. You were previously admitted for inpatient rehabilitation and were transferred to this hospital. The Plan has advised that the claim for the previous admission will be reprocessed to reflect a $0 co-payment. Therefore, we decided that the Plan does not have to waive the co-payment for the inpatient rehabilitation facility (IRF) care provided from
October 24, 2020, through November 3, 2020.