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

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says any drug, device, treatment or procedure that is experimental, investigational or unproven is not a covered benefit.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has lymphedema following mastectomy for breast cancer. The provided medical records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules of the requested service. There is insufficient literature to establish the requested test as safe and effective, as defined by Medicare rules, for the enrollee's specific clinical condition. The elements of the coverage criteria are not satisfied. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on December 21, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you should only be billed one $150 copayment because you were unable to complete the MRI on the first date of service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Medicare-covered complex diagnostic radiological services.
You have been asked to pay a $150 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI provided on December 21, 2020.
Your complaint about being penalized for your disability is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 11, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on December 11, 2020.
Appeal type: Lab
Decision: Favorable

We decided the Plan has to hold you harmless for an ultrasound provided on March 2, 2021 (minus any applicable copayment).
You asked the Plan to hold you harmless for these services. You say that this ultrasound should be covered by the Plan. The Plan denied your request. The Plan says that the service billed is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We found the case file submitted by the Plan did not clearly determine if you were or were not referred out of network. You would not have been aware of any billing and coding issues with the claim submitted by the provider as that is not within your scope of knowledge for this type of service. We asked the Plan for additional information however our request was not responded to. Therefor, we have decided the Plan is required to hold you harmless for the cost of this service (minus any applicable copayment).
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 incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you had surgery and need these
supplies. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. 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.
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: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided from September 22, 2020, to March 9, 2021. You asked the Plan to waive the coinsurance for the Part B drugs. You say that your treatments are now out-of-network because you cannot leave your state due to the corona virus. You say you should not be responsible for these amounts. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B drugs including chemotherapy drugs. You have been asked to pay a total of $5,549.48 for the Part B drugs. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. The record shows the claims were processed at the in-network level and amounts were applied to your maximum out-of-pocket amounts. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 22, 2020
Part B drug
$6,264
20%
$1,252.80
October 20, 2020
Part B drug
$6,483
20%
$403.28 - You met your 2020 maximum out-of-pocket amount with this claim.
November 17, 2020
Part B drug
$6,483
20%
$0
December 15, 2020
Part B drug
$6,483
20%
$0
January 12, 2021
Part B drug
$6,489
20%
$1,297.80
February 9, 2021
Part B drug
$6,489
20%
$1,297.80
March 9, 2021
Part B drug
$6,489
20%
$1,297.80
Total
$5,549.48
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 Part B drugs provided from September 22, 2020, to March 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 10, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 10, 2020.unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia services for an injection procedure.
You asked the Plan to pre-approve anesthesia services. The Plan denied your request. The Plan says the service 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 anesthesia services. Our physician reviewer found that this enrollee does not have a diagnosis, condition, or symptoms that meet the Medicare criteria for coverage of MAC. Although it was reported that she has a severe phobia of needles and requires monitored anesthesia care, he did not offer any additional clinical information. Therefore, the requested MAC/conscious sedation during the performance of a lumbar facet injection is not 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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia services for an injection procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet joint injections.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that diagnostic facet injections are covered when the criteria established in the applicable LCD 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 the injections. Our reviewer says that the requested injections are not medically reasonable and necessary in this case. Our physician reviewer found that the requirement is for 80% pain relief from each set of diagnostic medial branch blocks. This was not
achieved, and therefore, the request is not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar magnetic resonance imaging (MRI) scan (72148).
You asked the Plan to pre-approve a lumbar MRI. You say that this service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 a lumbar MRI. Our reviewer says that the requested MRI is not medically necessary and reasonable. Our physician reviewer found the patient is a 73-year-old female with low back pain. Tylenol #3 was helpful. The provided records did not show that the patient had tried and failed sufficient conservative treatments such as physical therapy prior to considering MRI and there were no clearly documented signs of a red flag diagnosis to justify earlier use of MRI. Therefore, this request for MRI will be considered not medically necessary 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 lumbar MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar magnetic resonance imaging (MRI) scan (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 10.
You asked the Plan to pre-approve a crown for tooth 10. You say that you want the services to preserve the condition of your teeth. The Plan denied your request. The Plan says the x-rays received by the dental vendor did not show evidence of a cavity under your current cap.
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 crown for tooth 10 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 a crown for tooth 10. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not show there is a need for a replacement crown on tooth #10. The radiograph does not show any obvious signs of recurrent decay that would require replacement of the crown.
There is no supplied documentation stating a specific need for a replacement of the existing crown. There is no support for the necessity for the new crown on tooth #10. 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 a crown for tooth 10 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 10.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility (IRF) admission provided from March 12, 2021, through March 15, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 he must pay a $325 copayment per admission for each medically necessary inpatient stay. The enrollee has been asked to pay a $325 copayment for the acute inpatient rehabilitation facility admission provided. 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 when he enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility (IRF) admission provided from March 12, 2021, through March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits in a home health setting (G0151).
You asked the Plan to pre-approve physical therapy visits. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for home health services have not been met because additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 physical therapy visits. Our reviewer says that the requested services are not medically necessary in this case. Our physician reviewer found that the provided documentation does not support that additional physical therapy visits are required at this time to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits in a home health setting (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided on January 27, 2021 by an out-of-network provider.
You asked the Plan to reimburse you for the dental services. You say that you were not told your plan would not cover your dentist in 2021. The Plan denied your request. The Plan says services are only covered when performed by a Plan provider and the 2020 claim was paid in error.
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 reimburse you 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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for the dental services provided on January 27, 2021 by an out-of-network provider.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 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.