Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient surgery services provided at an outpatient hospital facility on July 27, 2020.You asked the Plan to waive the copayment forthe outpatient surgery services. You say that you cannot afford this amount and you did not know you would be charged a facility fee for these services.The Plan denied your request. The Plan says this copayment was charged correctly.  The Plan says that because the allowed amount for the procedure ($248.64) is less than the copayment, the enrollee is responsible for the full billed amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $365 copayment for outpatient surgery in an outpatient hospital facility. The enrollee has been asked to pay a $365 copayment for the outpatient surgery services. These services occurred at an outpatient hospital facility. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foroutpatient surgery services provided at an outpatient hospital facility on July 27, 2020.
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 enrollee has had a prolonged hospital
stay and would benefit from LTACH care. The Plan denied your request. The Plan says there is no clinical
advantage to LTACH care over continued care at a short-term care hospital.
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 patient is a male who was admitted to the current acute care hospital on
10/26/2020 with a large recurrent intracranial hemorrhage requiring craniotomy on 11/7. He has been intubated
with trach placement on 11/20. PEG was placed, and he was treated with anti-seizure medication. Recent notes
show that he is now tolerating trach collar but is still being treated for infection and altered mental status.
The patient appears to be improving but still requires additional short-term acute care services to help further
stabilize the patient which can be safely completed at the current facility. The patient does not require services
at the LTACH that are not already available and covered at the current facility. Therefore, this request for
LTACH services will be considered not medically necessary at this time. Transfer may be considered when the
patient's treatment has completed and they are more appropriate for a lower level of care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous image-guided lumbar decompression for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that this service is considered experimental, investigational or unproven.The Plan must follow Medicarerules. Medicare rules say that percutaneous image-guided lumbar decompressionis covered if the above criteria are met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the percutaneous image-guided lumbar decompression have not been met. Specifically, the record does not show that the enrollee is participating in an approved clinical study through Coverage with Evidence Development.Therefore, we decided that the Plan does not have to pre-approvepercutaneous image-guided lumbar decompression for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, two anterior resin-based composites of two surfaces, two anterior resin-based composites of four or more surfaces or involving incisal angle, posterior resin-based composite of one surface, and posterior resin-based composite of two surfaces provided from January 24, 2020, to February 18, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation and resin-based composites. You say that you did not realize that this care would not be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider without prior authorization. The Plan also says that these services were neither emergency or urgent dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, two anterior resin-based composites of two surfaces, two anterior resin-based composites of four or more surfaces or involving incisal angle, posterior resin-based composite of one surface, and posterior resin-based composite of two surfaces provided from January 24, 2020, to February 18, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Joint Active System (JAS) for the left wrist (a wrist orthosis).You asked the Plan to pre-approvea wrist orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item 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 a wrist orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a history of a closed Colle's fracture of the left radius. You were given a pre-fabricated wrist brace on July 29, 2020 and instructed on use. The documentation does not reveal that the addition of the JAS devices significant improves enrollee clinical outcomes therefore, this is not proven to be the standard of care for your condition. Therefore, you do not meet criteria for the requested item.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 wrist orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea Joint Active System (JAS) for the left wrist (a wrist orthosis)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Special Breathing Machine (CPT Code E0601-X1) and (E0562-X1).You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says the criteria state that you must use the machine for more than 4 hours per night on 70% of nights during a one-month period and this is not documented in the information submitted.We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules to determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found the criteria for continued coverage of continuous positive airway pressure (CPAP) are not met. You have obstructive sleep apnea (OSA) with previous use of CPAP, but are reportedly experiencing excessive daytime sleepiness. However, there is no clinical visit documenting this. A telemedicine visit on September 15, 2020, does not mention sleep symptoms. The compliance report covering the month prior to that visit does not meet minimum usage criteria, but also shows significant residual respiratory events while on CPAP, suggesting the settings may be ineffective. Currently, CPAP is considered not medically necessary because minimum usage criteria are not met, and the denial is upheld. You would need a current clinical evaluation to address CPAP therapy.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 DMEhave not been met.Therefore, we decided that the Plan does not have to pre-approvea Special Breathing Machine (CPT Code E0601-X1) and (E0562-X1).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening mammography services (77067) and a screening digital breast tomosynthesis (77063) billed for date of service July 29, 2020.You asked the Plan to pay forthe screening mammogram and the screening digital breast tomosynthesis. You say that the claim should be reprocessed for payment, as your coding diagnosis is correct.The Plan denied your request. The Plan says due to the discrepancy in place of treatment between the facility claim and physician claim for the diagnosis code billed, a corrected claim is required to eliminate the billingerror.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must supply information to corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Providers must bill with the correct site-of-service so that appropriate physician and practitioner payment amounts can be determined. The records show that the screening mammography services were billed with a 23place of service (POS) code. There was no medical documentation demonstrating that this was where the screening services were performed, nor was there evidence of why the screening services would be performed in an emergent setting. The appellant has not provided sufficient information to support the site-of-service was billed correctly. Based on this information, we decided that Medicare rules for coverage of the screening mammogram and the screening digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay forscreening mammography services (77067) and a screening digital breast tomosynthesis (77063) billed for date of service July 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoutpatient physical therapy to be provided by a non-participating provider.You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says your request for coverage is not urgent or emergent and there are contracted providers available in the area who are able to provide the service.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-approveoutpatient physical therapy to be provided by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintraoral -periapical first radiographic image (X-Ray (D0220) provided on March 20, 2020.You asked the Plan to pre-approveintraoral X-Ray. You say that the service was medically necessary.The Plan denied your request. The Plan says preventive dental care covers bitewing X-rays, but the service rendered was an intraoral X-ray, which does not fall under preventive dental care and therefore 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-approveintraoral -periapical first radiographic image (X-Ray (D0220) provided on March 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous device. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 insertion of interlaminar/interspinous
device. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has back pain. The requested spacer remains
experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet
criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of interlaminar/interspinous device have not been met. Therefore, we
decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe right open sacroiliac joint fusion (27280).You asked the Plan to pre-approvethe sacroiliac joint fusion. You say that your medical diagnosis is a degenerative disc disorder and the surgery will benefit your physical health. You need constant assistance and feel the surgery will improve your quality of life.The Plan denied your request. The Plan says this service is experimental or has not been proven to be safe or effective for your diagnosis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sacroiliac joint fusion have not been met.Therefore, we decided that the Plan does not have to pre-approvethe right open sacroiliac joint fusion (27280)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral-periapical X-rays (D0220 and D0230) and an unspecified preventive procedure (D1999) performed on August 12, 2020.You asked the Plan to pay forintraoral-periapical X-rays and an unspecified preventive procedure. You say that these services were requires for preventive health care essential to identify and treat dental infirmities before they become critical.The Plan denied your request. The Plan says rules for payment have not been met.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 forintraoral-periapical X-rays (D0220 and D0230) and an unspecified preventive procedure (D1999) performed on August 12, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care and neurofeedback provided out of network from June 30, 2020, to July 30, 2020.You asked the Plan to pay forthis service. You say that there are no providers  in network who offer neurofeedback.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that outpatient mental health care requires prior authorization. The Plan did not pre-approve treatment with this provider. It should also be noted the treatment provided is not covered by Medicare. Therefore, we decided that the Plan does not have to pay foroutpatient mental health care and neurofeedback provided out of network from June 30, 2020, to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network chiropractic care provided on August 11, 2020, to August 13, 2020.You asked the Plan to pay forout of network chiropractic care. You say that you thought this care would be covered.The Plan denied your request. The Plan says you did not have prior authorization for out of network chiropractic care.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 careand pre-approved care.The Plan contract also states that chiropractic must be provided in network. The 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 forout of network chiropractic care provided on August 11, 2020, to August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortopical application of fluoride (D1206) provided on August 13, 2020.You asked the Plan to pay fortopical application of fluoride. You say that the services should be covered.The Plan denied your request. The Plan says the 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. The plan covers services listed in the EOC.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. Specifically, this service is not listed in the Plan's EOC and therefore, is not a covered benefit.Therefore, we decided that the Plan does not have to pay fortopical application of fluoride (D1206) provided on August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services you received on July 19, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you have never paid a copayment for ambulance services in the past.The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for ambulance services.You have been asked to pay a $200 copayment for the ambulance services. 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment forambulance services you received on July 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRetacrit for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation does not support the enrollee has low or intermediate risk disease.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review has determined that the documentation does not support that the Retacrit is medically reasonable or necessary. The enrollee has high risk myelodysplastic syndrome. The documentation does not support low or intermediate risk disease. The documentation does not support that the Retacrit is safe and effective.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRetacrit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required, two prefabricated post and cores in addition to crowns, and three crowns.You asked the Plan to pre-approvethe core buildup, prefabricated post and cores, and crowns. The Plan denied your request. The Plan says these services are not covered under the enrollee's contract or the Medicare program under any normal circumstances.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-approvea core buildup, including any pins when required, two prefabricated post and cores in addition to crowns, and three crowns.