Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography image (D0364) provided on March 10, 2021.
You asked the Plan to pay for a cone beam computed tomography image. You say that you want the Plan to provide an adjustment for the type of image used. The Plan denied your request. The Plan says the service at issue 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 pay for a cone beam computed tomography image (D0364) provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the necessary care can be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Aduhelmf or the enrollee.
You asked the Plan to pre-approve Aduhelm. You say that the enrollee meets clinical criteria for Aduhelm. The Plan denied your request. The Plan says that that no clinical coverage criteria exists for this drug at this time and it is not currently covered by original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aduhelm. Our reviewer says that Aduhelm is medically reasonable and necessary for the enrollee in this case. The enrollee has rapidly progressive dementia and has failed therapy with Aricept and Memantine. The review indicates that the requested use of Aduhelm is FDA-approved for the enrollee's diagnosis. Currently available therapies only treat symptoms of the disease; this treatment option is the first therapy to target and affect the underlying disease process of Alzheimer's. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Aduhelm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have been met. Therefore, we decided that the Plan has to pre-approve Aduhelmf or the enrollee.
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: Testing
Decision: Unfavorable

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented clinical status change that would establish medical necessity of repeat polysomnography.
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 study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a repeat study with positive airway pressure (PAP) titration is not medically necessary. You were diagnosed with obstructive sleep apnea on a sleep study in 2013, and you have been doing well on nightly continuous positive airway pressure (CPAP). There is good compliance and the device has been effective. It is now nearing the end of its mechanical life and needs to be replaced. A new study is not needed to replace the device. It is only necessary if the current settings are not effective and/or there have been major changes in your weight or health status. The device should be replaced and continued at the current settings. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography with continuous positive airway pressure (CPAP).We decided that the Plan does not have to pre-approve polysomnography with continuous positive airway pressure (CPAP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 23, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that your periodontist recommends that you see her for cleanings and consistency of care. You also say that you would like the periodontal maintenance to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 periodontal maintenance (D4910) provided on November 23, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 23, 2021.
You asked the Plan to pay for the ambulance response and treatment. You say that you fainted in church and were checked out across the street by Emergency Medical Services (EMS). You say they treated and checked you out and you were told you would not be charged for these services. The Plan denied your request. The Plan says Medicare and the Plan only cover ambulance services when transportation is provided. When you are not transported anywhere, there is no payable service.
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 January 23, 2021. Documentation shows that you refused transportation, and a signed Notice of Noncovered Services form was included. 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 response and treatment with no transport (A0998) provided on January 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology imaging provided by a participating provider on March 11, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that everything from your transplant would be covered. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $100 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay a $100 copayment for an ultrasound. Post-op appointments and services are subject to the correct copayment; therefore, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 diagnostic radiology imaging provided by a participating provider on March 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS heart failure device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary to help volume status. The Plan denied your request. The Plan says that there are not enough robust studies to prove a mortality or morbidity benefit using this device as opposed to optimal medical management and close follow-up.
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 device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe ischemic heart failure, with depressed ejection fraction (EF) and New York Heart Association (NYHA) Class III symptoms. The enrollee is on appropriate guideline-directed congestive heart failure (CHF) medications (using isordil/hydralazine as he cannot tolerate Entresto or sprinolactone due to renal insufficiency) with recent hospitalization for CHF within the past 6 months. He has been meticulously managed with frequent adjustments of his medical regimen due to his hypotension (previously on fluorine) and increasing renal insufficiency making diuretic management difficult using just clinical symptoms, signs and weights alone, and he has been hospitalized within the last year for decompensated failure. The requested device can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens especially in patients with baseline renal insufficiency like this man who is very volume sensitive to cardiac loading conditions. Use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational based on these data backed indications and would meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule. 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 device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS heart failure device for the enrollee.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 18, 2019. u asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
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 97163 is not supported in the medical record. Specifically, the corrected claim was not billed with an appropriate occupational therapy CPT code or required modifier. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for x-rays (72040, 73070, 72100) provided March 18, 2021.
You asked the Plan to waive the copayments for the x-rays. You say that there should not be three separate copayments applied. The Plan denied your request. The Plan says three separate x-rays were taken so the correct cost-sharing was applied.
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 $20 copayment for x-rays. You have been asked to pay $60 for 3 separate x-rays ($20 each). 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 copayments for x-rays (72040, 73070, 72100) provided March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nursing facility visit provided on March 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that medically necessary services were provided at the request of the facility medical director or primary care provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 a nursing facility visit provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for dialysis services provided from January 1, 2021, to February 26, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct and you thought it would be the same cost paid in 2020. The Plan denied your request. The Plan says this coinsurance was charged based on the services provided and your Plan contract agreement. 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% coinsurance for dialysis services. 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 or reduce the cost share charged for dialysis services provided from January 1, 2021, to February 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the 20% coinsurance charged for outpatient surgery services provided on February 22, 2021.

You asked the Plan to waive or reduce this coinsurance. You say that you were not told this coinsurance would be so high. The Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the Plan contract agreement.

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% coinsurance for outpatient surgery. 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 or reduce the 20% coinsurance charged for outpatient surgery services provided on February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve venography.

You asked the Plan to pre-approve venography. 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 venography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not support that requested service is not medically necessary or reasonable as defined by Medicare rules. The elements of the coverage determination are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of venography have not been met. Therefore, we decided that the Plan does not have to pre-approve venography.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation with an out-of-network provider.
You asked the Plan to pre-approve second opinion consultation. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary as there is available care in-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 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-approve a second opinion consultation with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on April 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network dental 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 requested services are not among those covered under this benefit. The services were provided to you by an out-of-network provider. The Plan does not cover out-of-network dental services.

Therefore, we decided that the Plan does not have to pay for the dental services you received on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided
from March 17, 2020, to March 18, 2020.

You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you did not know
you were an outpatient. The Plan denied your request. The Plan says you were charged the coinsurance
correctly for the outpatient services.

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 25%
coinsurance for Outpatient Surgery.

You have been asked to pay 25% coinsurance for the outpatient surgery services. The outpatient surgery
services fall within the Outpatient Surgery 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 outpatient surgery services provided from March 17, 2020, to March 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee has exhausted there SNF benefit of 100 days.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 26, 2021- February 27, 2021 (1 day), March 8, 2021-March 24, 2021 (16 days), April 23, 2021-May 21, 2021 (28 days), May 22, 2021-May 25, 2021 (3 days), May 28, 2021-June 11, 2021 (14 days), June 17, 2021-July 5, 2021 (18 days), July 22, 2021-August 4, 2021 (14 days), and August 4, 2021-August 10, 2021 (6 days). The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.