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

We decided that the Plan does not have to waive the copayment forthe office visit provided on March 5, 2020.You asked the Plan to waive the copayment forthe office visit. You say that the only visit you had in 2020 was in January.The Plan denied your request. The Plan says the copayment 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were seen on March 5, 2020 for a cardiac follow up. 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 forthe office visit provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you were medically stable with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from further PT and an OT but do not require an intensive therapy program. IRF admission is not medically necessary based on your current medical status and stability. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that the enrollee was seen in an emergent setting. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The documentation submitted shows that this hospital visit was elective in nature and not emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses and frames purchased January 25, 2020 by an out-of-network provider.You asked the Plan to pay for the vision services. You say that the provider assured you that you would be covered and all you had to do was fill out the form and  you would then be reimbursed.The Plan denied your request. The Plan says vision services provided by an out-of-network provider is not covered by the plan.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 services when they are rendered by an in-network provider.We looked at the file and the Plan's rules. You must use an in-network provider for routine coverage including, routine exam, retinal imaging and eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for lenses and frames purchased January 25, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0481 provided on August 27, 2019.
You asked the Plan to pay for CPT code G0481. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. We find that CPT code G0481 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 8-14 drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code G0481 provided on August 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested CT scan of the chest is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the chest is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan of the chest. Our reviewer says that the requested CT scan of the chest is not medically necessary. Our physician reviewer found the enrollee is with a history of interstitial pulmonary fibrosis. The documentation indicates that the enrollee had a previous chest CT scan September 27, 2019, and that clinical status when evaluated March 23, 2020 was without significant change except for a slight decrease in diffusion capacity on pulmonary function testing compared to January 2019. It was specifically stated that cough was overall improved. The plan was to increase the dosing of Ofev, follow liver function tests and to see the enrollee in follow up 6 months. It was stated in the medical records at the visit on March 23, 2020 that testing including, but not limited to, high resolution chest CT should be done at least on an annual basis. It was specifically noted that HRCT was ordered to be completed prior to the next visit which was stated to be in 6 months. The documentation does not indicate that a repeat CT scan of the chest at this time is 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the deductible forlaboratory testing provided on January 16, 2020.You asked the Plan to waive the deductible forlab test. You say that you were informed that laboratory services were covered with no cost-sharing under this plan.The Plan denied your request. The Plan says that the deductible amount you are being charged is correct.The rules say a plan must disclose toits enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that lab services are excluded from the Plan deductible. Your contract with the Plan also says that you pay $0 copayment for in-network lab services.The Plan says you must pay $1,000 deductible for lab test. Based on the Plan contract, however, lab tests are excluded from the deductible and you cannot be asked to pay more than $0 copayment for lab test. Therefore, we decided that the Plan has to waive the deductible forlaboratory testing provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for computerized ophthalmic diagnostic imaging (92133) and refraction services (92015) provided February 27, 2020.
You asked the Plan to pay for the vision services. You say that you would like to appeal the denial of the services. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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. These services are not listed as covered services. We looked at the file and the Plan's rules. These services are not listed as covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for computerized ophthalmic diagnostic imaging (92133) and refraction services (92015) provided February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee injection.
You asked the Plan to pre-approve knee injection. 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 follows Medicare rules. Medicare rules say that knee injections are only covered for certain indications. 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 knee injection. Our reviewer says that the requested injection services are not medically reasonable or necessary. Our physician reviewer found you have chronic right knee pain. You are status post total knee arthroplasty. Your post-operative course was complicated by infection. You have had trials of Physical Therapy, Percocet, LorTab, Gabapentin and Flexeril. The requested injection services are considered an experimental/ investigational procedure that is the subject of on-going clinical trials. You are not enrolled in a clinical trial. Therefore, you do 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 knee injection have not been met. Therefore, we decided that the Plan does not have to pre-approve knee injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections (Q5106), administration, and
treatment.
You asked the Plan to pre-approve Retacrit, administration, and treatment. The Plan denied your request. The
Plan says Retacrit is not medically necessary at this time. The Plan also says that the Plan's prior authorization
coverage criteria has not been met.
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 Retacrit. Our reviewer says that
Retacrit is not medically reasonable and necessary. Our physician reviewer found the use of Retacrit is
supported by the Food and Drug Administration label and the compendia when the hemoglobin is less than 10.
The enrollee's hemoglobin was 10.8 on testing done on June 2, 2020. Our reviewer found that the submitted
documentation does not indicate that the enrollee has had transfusions. Our physician reviewer also found that
the documentation does not support that the use of Retacrit is medically reasonable and necessary or safe and
effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit injections (Q5106), administration, and treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary because you have vertigo and tends to become very dizzy at times and you may fall in the shower when you get dizzy. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 19, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says with limited exceptions, the enrollee may be required to use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out of area dialysis, and cases in which the Plan authorizes use of out-of-network providers.
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 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 subsequent nursing facility care provided on November 19, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT Scan of the head or brain (70450) provided on January 9, 2020. You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this claim denied as a duplicate in error. The Plan denied your request. The Plan says that procedure code 70450 is considered as being the column II code to the more comprehensive column I code 70460 and a modifier is not allowed with the code pair. 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 70450 is supported in the record. Specifically, NCCI edits apply to line items for the same beneficiary, same NPI and same date of service. The record indicates that these services were rendered by separate providers with different NPI numbers. Based on this information, we decided that Medicare rules for coverage of the CT Scan have been met. Therefore, we decided that the Plan has to pay for a CT Scan of the head or brain (70450) provided on January 9, 2020. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous and/or interlaminar device.
You asked the Plan to pre-approve interspinous and/or interlaminar 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 interspinous and/or interlaminar 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 lumbar pain. The requested device 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 interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous and/or interlaminar device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010).
You asked the Plan to pre-approve the endosteal implant. You say that you are wondering if you will have to pay anything to receive the dentures you were approved for. The Plan denied your request. The Plan says this service is not listed as 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-approve a surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the credit for the second pair of eyeglasses provided on February 28, 2020.
You asked the Plan to pay the credit for the second pair of eyeglasses. You say that the Plan should pay you a $100 credit for the eyeglasses. The Plan denied your request. The Plan says they gave you a $100 credit for the eyeglasses purchased on February 27, 2020.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay the credit for are considered routine vision services or eyewear. You have exceeded the limits of your benefit. Therefore, we decided that the Plan does not have to pay the credit for the second pair of eyeglasses provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction and bone replacement graft provided on July 30, 2019.You asked the Plan to pay forthe extraction and bone replacement graft. You say that according to your physician's statement and x-rays, this was a medical service.The Plan denied your request. The Plan says the documentation does not show these services were performed in preparation for radiation treatments for neoplastic disease. The Plan also says that these services are not medically necessary and are not covered under the medical plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe extraction andbone replacement graft provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 3, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says services from non-participating providers are not covered under the enrollee's plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 subsequent nursing facility care provided on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on December 20, 2019.
You asked the Plan to pay for the resin-based composites. You say that you had a buy in of $150 that should be paid back to you. The Plan denied your request. The Plan says enrollees can be reimbursed up to $150 per year for preventive services only. The Plan also says that these services are not covered benefits.
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 because they are not preventive services. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on December 20, 2019.