Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pre-made shoulder brace.
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your request. The Plan says a pre-made shoulder brace is not medically necessary for your condition.
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 brace. Our reviewer says that the requested brace is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, the Criteria for Authorization and Reimbursement - Orthotics and the Social Security Act, Section 1862(a)1(A), the shoulder brace in this case is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a pre-made shoulder brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra (J3262).You asked the Plan to pre-approve the Actemra. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan saysMedicare's drug compendia, coverage determinations and medical journals do not support the use of this drug to treat antibody mediated rejection of transplanted heart.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 Actemra. Our reviewer says that the use of Actemra is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the use of Actemra is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal and there is no reference to use of Actemra for treatment of antibody mediated rejection of the transplanted heart in any of the compendia. 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra (J3262).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia, retreatment of
previous root canal therapy, and amalgam provided on November 26, 2019.
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia, retreatment of previous root canal
therapy, and amalgam. You say that you say that the services were provided immediately and necessary to treat
your pain. You also say that you are on a limited income. The Plan denied your request. The Plan says that
nitrous oxide is not a covered benefit. The Plan also says that you exceeded the limits set in the subscriber
agreement.
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, nitrous oxide is not among those
covered under this benefit. The contract also clearly states that there is an annual maximum benefit of $1,100,
reduced by any Out-Of-Network Dental benefits, every year. The record shows that you met the annual
maximum benefit on November 26, 2019, the Plan contributed the remaining $457.20 of your annual benefit
toward these services, and your annual maximum benefit had been exhausted. Therefore, we decided that the
Plan does not have to pay for the inhalation of nitrous oxide/analgesia, retreatment of previous root canal
therapy, and amalgam provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on October 30, 2019.You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The Plan states payment for these services is the responsibility of the facility.The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not considered to be effective.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental, and more research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray provided on July 13, 2019.You asked thePlan to pay forthe x-ray. You say that you would like the plan to reconsider their denial.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.In this case, the CPT Code Manual definition of code 73140 is radiologic examination, finger(s), minimum of 2 views.We find that CPT code 73140 is not supportedin the medical record. Specifically, the diagnosis code(s) associated to this code are mismatched to the procedure modifier on the claim line. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray provided on July 13, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to reduce the cost forthe colorectal cancer screening. We decided that the Plan does not have to waive the coinsurance forthe colorectal cancer screening. You asked the Plan to waive the deductible forthe colorectal cancer screening. You say that you were not informed that the provider was not in-network. You say you were under the impression that this test was preventive.The Plan says that the claim did not deny and you have been charged the correct cost sharing amount. We decided that the Planhas to reduce the cost forthe colorectal cancer screening. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The colorectal cancer screening is considered a zero-dollar preventive service received from an out-of-network provider, therefore the deductible does not apply.The Plan says that you must pay $498.69 toward the deductible. Based on the plan contract, however, you cannot be asked to pay more than 35% of the allowed amount. ($498.69 x 35% = $174.54). Therefore, we decided that the Plan has to waive the $498.69 deductible amount and apply the 35% coinsurance amount of $174.54. We also decided that the Plandoes not have to waive the coinsurance forthe colorectal cancer screening.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 35% coinsurance for the colorectal cancer screening.Therefore, we decided that the Plan does not have to waive the coinsurance forthe colorectal cancer screening.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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bariatric surgery (laparoscopic gastric sleeve) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that given the severe level of obesity, multiple obesity-related comorbities, and inability for sustained weight loss, this is a reasonable course to pursue. The Plan denied your request. The Plan says that there was no evidence submitted in the records regarding diligent efforts to achieve a healthy body weight, or failure to maintain a healthy weight despite taking part in a structured dietary program.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple weight-related co-morbid conditions, including hypertension, gastroesophageal reflux disease (GERD), coronary artery disease, severe sleep apnea, and diabetes. The enrollee has failed dietary efforts. The enrollee's BMI is over 35. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve bariatric surgery (laparoscopic gastric sleeve) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora monitoringfeature (A9279) provided on October 17, 2019.You asked the Plan to pay forthe monitoring feature. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code A9279 has a status code of I which is not valid for Medicare purposes.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 A9279 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code A9279 has a status code of I. This means that CPT code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the monitoring feature have not been met.Therefore, we decided that the Plan does not have to pay fora monitoring feature (A9279) provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthoses provided to the enrollee on November 15, 2019.You asked the Plan to pay for the orthoses. You say that these items were medically necessary.The Plan denied your request. The Plan says that the billed supply code cannot be verified.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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The medical records in the case file do not contain documentation of wrist pain, or abnormality of the wrists on physical examination. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthoses.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for the wrist/hand orthoses provided to the enrollee on November 15, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for CPT code 81163 provided on June 28, 2019.
You asked the Plan to pay for CPT code 81163. You say that the medical records support the billing of code 81163. The Plan denied your request. The Plan says that the medical records do not support the billing of code 81163.
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 81163 is BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis. 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 CPT code 81163. Our physician reviewer found based on the documentation provided for review the medical records support the billing of CPT code 81163 for BRCA 1/2. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 81163 have been met. Therefore, we decided that the Plan has to pay for CPT code 81163 provided on June 28, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on November 19, 2019.You asked the Plan to pay for the ECG. The Plan denied your request. The Plan says prior 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 did not pre-approve the servicesat 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 for an electrocardiogram (ECG) provided on November 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis Tablets 5mg.You asked the Plan to pre-approveEliquis Tablets. You say that this enrollee has persistent atrial fibrillation and has been responding well to treatment.The Plan denied your request. The Plan says this medication is not covered benefit and does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEliquisTablets 5mg.Benefits for Eliquis Tabletsmay be available under Medicare Part D. Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on December 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on December 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on June 25, 2019 and September 24, 2019.
You asked the Plan to waive the copayments for the ambulance rides. You say that you would like the copayments waived because the transportation via ambulance was due to necessity and not convenience. The Plan denied your request. The Plan says you have been charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip. The enrollee has been asked to pay a $250 copayment for the ambulance rides. The ambulance rides fall within the "Ambulance services" benefit category. 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 copayments for the ambulance rides provided on June 25, 2019 and September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on September 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 96361 is 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 96361 is intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure).We find that CPT code 96361 is not supported in the medical record. Specifically, there is no documentation of the time over which the infusion was administered to the patient. 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 forthe services rendered on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide additional reimbursement for the lenses provided on November 18, 2019.
You asked the Plan to provide additional reimbursement for the lenses. You say that The Plan denied your request. The Plan says that that the claim processed and paid with a $100 plan benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these frames and lenses up to $100. We looked at the file and the Plan's rules. The file indicates the Plan only paid $60 towards the $100 plan allowance for frames and lenses. The other $40 the Plan paid was for a routine eye exam. Therefore, we decided that the Plan has to provide additional reimbursement for the lenses provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.You asked the Plan to pre-approve the supplement. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit if taken orally.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 15, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says you were not referred by a network provider.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 has network providers available who can provide 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 pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Diclofenac Epolamine patch.
You asked the Plan to pre-approve the Diclofenac Epolamine patch. You say that alternate drugs previously tried had an adverse outcome. The Plan denied your request. The Plan says the requested medication is not covered under your medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Diclofenac Epolamine patch.
Benefits for the Diclofenac Epolamine patch may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.