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

We decided that the Plan has to pre-approve sacroiliac joint injections (27096).
You asked the Plan to pre-approve sacroiliac joint injections. You say that this is medically necessary. The Plan
denied your request. The Plan says that this is only allowed once a year.
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 sacroiliac joint injections. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found that the record shows you have Sacroiliitis and have had prior sacroiliac joint injections which
have provided 6-9 months of pain relief. The last injection only provided 3 months of pain relief. Current
medical literature supports up to 3 injections per year. A study found a median effective duration of 36 weeks.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint injections have been met. Therefore, we decided that the Plan
has to pre-approve sacroiliac joint injections (27096).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the CT scan and contrast material provided on October 16, 2020.
You asked the Plan to waive the cost for the CT scan and contrast material. You say that you have this test every year and have never had a copayment. You say that this was coded wrong, but the claim has not been fixed. The Plan denied your request. The Plan says the cost share applied 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 $175 copayment for each in-network, Medicare-covered diagnostic imaging service and 20% coinsurance for in-network, Medicare-covered supplies. You have been asked to pay a total of $176.06 for the CT scan and contrast material.
Service
Allowed Amount
Standard Cost
Member Liability
CT scan
$647.17
$175
$175
Contrast Material
$5.30
20%
$1.06
TOTAL:
$176.06
The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The contrast material falls within the "Outpatient hospital services" benefit category. The records show a diagnostic CT scan was billed. 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 cost for the CT scan and contrast material provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep medicated filling (D3120) for tooth # 2 provided on
February 3, 2021.
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied
your request. The Plan says deep medicated filling 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, 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 deep
medicated filling (D3120) for tooth # 2 provided on February 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on
September 29, 2020.
You asked the Plan to pay for the diagnostic radiology 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 unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 diagnostic radiology services provided on
September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on February 12, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you did not ask for this service specifically, just whichever x-ray was covered by your Plan. The Plan denied your request. The Plan says this type of x-ray is not covered by your 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 bitewing x-rays (D0274) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided from November 2, 2020, through November 16, 2020.
You asked the Plan to waive the copayment for occupational therapy. You say that payment was not asked for when you went for your appointment's and you were not told you owed anything. You say that you were told your insurance covered all the charges and you wouldn't be required to pay anything. The Plan denied your request. The Plan says the copayments applied 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 $25 copayment for each in-network, Medicare-covered occupational therapy visit.
You have been asked to pay a $25 copayment for each for occupational therapy visit. The total amount you owe is $100 ($25/visit x 4 visits = $100). Occupational therapy falls within the "Outpatient rehabilitation 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 copayment for occupational therapy provided from November 2, 2020, through November 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on August 16, 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 Current Procedural Terminology (CPT) code 97110 59 GP (1 unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas,each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the procedure report documents instruction given to patient for home exercises, however, does not document actual physical therapy session was performed. Therefore, CPT 97110 cannot be confirmed as performed.
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 pay for physical therapy services (CPT 97110) provided to the enrollee on August 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
received December 29, 2020.
You asked the Plan to pay for the problem focused oral evaluation. You say that the services were rendered innetwork
and should be paid for by the Plan. The Plan denied your request. The Plan says the requested service
is not covered under the enrollee's 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
limited oral evaluation - problem focused (D0140) received December 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of intra-abdominal tumors (49203), an anteroposterior colporrhaphy (57265), and a vaginal hysterectomy (58260) performed on September 25, 2020.
You asked the Plan to pay for an excision of intra-abdominal tumors, an anteroposterior colporrhaphy, and a vaginal hysterectomy. You say that the provider in question was requested to assist in the enrollee's surgery by the supervising physician. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for an excision of intra-abdominal tumors (49203), an anteroposterior colporrhaphy (57265), and a vaginal hysterectomy (58260) performed on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions and tuberosity reduction.
You asked the Plan to pre-approve the requested services. You say that you are in pain and cannot eat. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that extractions of 12 teeth were requested. The plan approved 2 extractions. We looked at the file and the rules. The Plan only covers 2 extractions per calendar year. Therefore, we decided that the Plan does not have to pre-approve additional extractions.
The file shows that a surgical reduction of osseous tuberosity was requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the tuberosity reduction.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need an
intensive therapy program with multiple visit from a rehab doctor per week.
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 physician reviewer found
that you were admitted to the acute care hospital for hypertensive urgency and pulmonary edema. Your medical
conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies,
including either physical or occupational therapy, in an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation procedure.
You asked the Plan to pre-approve cervical facet joint radiofrequency ablation procedure.. You say that the requested service is medically necessary. The Plan denied your request. The Plan says the criteria for the requested procedure have not been met.
The Plan follows Medicare rules. Medicare rules say that the enrollee must have had at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain 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 cervical facet joint radiofrequency ablation procedure. Our reviewer says that the requested service is not medically necessary and reasonable. Our
physician reviewer found that this 67-year-old woman has chronic neck pain. She has tried Botox, Chiropractic therapy, acupuncture, and massage. The LCD requires dual diagnostic MBBs achieving 80% pain relief. Since a second set has not been performed, the request for RFA is considered not medically reasonable or 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 cervical facet joint radiofrequency ablation procedure. have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical facet joint radiofrequency ablation procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the lithotripsy provided on December 2, 2020.
You asked the Plan to reduce the cost for the lithotripsy. You say that you were not advised that this part of the hospital was out-of-network. You say that you should not have to pay the out-of-network deductible and coinsurance. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that you must pay 20% coinsurance of the Medicare-allowed amount after the $1,000 yearly out-of-network deductible.
The item or service you asked the Plan to reduce the cost for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the lithotripsy was received on December 2, 2020. Therefore, $928.77 has been applied to meet your deductible.
Since the $1,000 deductible was met, you have also been asked to pay $417.95, which is 20% of the allowed amount for the lithotripsy. The allowed amount is $2,089.77 (20% x $2,089.77 = $417.95). 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 reduce the cost for the lithotripsy provided on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance transportation (A0429), and ground mileage (A0425) provided on December 1, 2020.
You asked the Plan to pay for emergency ambulance transportation, and ground mileage. You say that you want the Plan to pay for the services at issue. The Plan denied your request. The Plan says information provided at the time of the appeal does not support medical necessity for an emergency ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 pay for emergency ambulance transportation, and ground mileage. Our reviewer says that the documentation does not support than the emergency ambulance
transport was medically reasonable and necessary. The documentation also does not support that another means of transport were contraindicated in this case. Our physician reviewer found the patient was constipated the night before, took a stool softener, and began to have diarrhea. The patient stated that she was newly diagnosed with gastroesophageal reflux disease and thought that her abdominal pain was from that. The patient did not appear to be in any distress and her vital signs were normal. The patient was able to get up and ambulate without assistance. She was assisted to the stretcher. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of emergency ambulance transportation, and ground mileage have not been met. Specifically, criteria for medical necessity of an emergency ambulance transport were not met. Therefore, we decided that the Plan does not have to pay for emergency ambulance transportation (A0429), and ground mileage (A0425) provided on December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endovenous ablation rendered on January 22, 2021.
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 services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific
criteria 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found there is insufficient documentation
regarding the enrollee's symptoms prior to his numerous ablation procedures and no clarity with respect to how
he responded to these procedures. There is a lack of clarity in the notes. Furthermore, there is no documentation
of absence of deep vein thrombosis or the presence of significant reflux in the vein that was treated on the day
in question. The records do not support that the services were reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the endovenous ablation rendered on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive air pressure (CPAP) device supplies.
You asked the Plan to pre-approve CPAP supplies. You say that the enrollee has not been able to use the CPAP due to a medical condition. The Plan denied your request. The Plan says the records do not show the enrollee has had a consistent use of the CPAP for at least four hours per night for 70% of nights.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous positive air pressure (CPAP) device supplies.