Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99284) provided March 13, 2020.You asked the Plan to waive the copayment forthe Emergency Room Visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 $90 copayment for Emergency Care. The enrollee has been asked to pay a $90 copayment for the Emergency Room Visit.The Emergency Room Visit falls within the Emergency Care 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 copayment for an Emergency Room Visit (99284) provided March 13, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms identified with CPT 77295.You asked the Plan to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.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 orservice 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 3-dimensional radiotherapy plan, including dose-volume histograms. Our reviewer says that the documentation supports that the requested services are medically reasonable or necessary. Our physician reviewer found the physician did provide a letter describing the need for 3D planning and provided the rationale that the patient has a large BMI such that 4-field plan and review of a dose volume histogram would be needed to assure no unacceptable not spots. Generally, 3D radiation is necessary when the 2D radiation plan results in unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation. The rationale provided in the case file is plausible and appears to be an exceptional situation for which the need of 3D RT can be justified. The documentation supports that the need for 3D radiation has been substantiated in this case and that it would be within accepted standards of care to use 3D as opposed to 2D radiation.Our reviewer also said that the Local Coverage Determination (LCD), L34151 used by the plan is for SRS/SBRT which would not apply in this case. Therefore, we did not use LCD L34151 to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3-dimensional radiotherapy plan, including dose-volume histograms have been met.Therefore, we decided that the Plan has to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms identified with CPT 77295.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 thereis 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 a total knee arthroplasty.
You asked the Plan to pre-approve the total knee arthroplasty. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the surgery should not be done if you have the inability to extend your knee and this cannot be corrected with surgery.
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 total knee arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication presented to support the isolated total knee arthroplasty in the setting of quadriceps rupture and extensor mechanism dysfunction. The physician reported in his February 13, 2020 report that your knee could not be replaced with a rupture of the extensor tendon. 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 total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix.
You asked the Plan to pre-approve Trintellix. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Trintellix.
Benefits for Trintellix may be available under Medicare Part D. Contact the
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care services.
You asked the Plan to pre-approve home health services. You say that the enrollee requires skilled nursing
intervention for medication instruction and monitoring all body systems. The Plan denied your request. The
Plan says the denial of authorization for home health care is correct.
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 home health services. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician
reviewer found the enrollee does not have documented skilled nursing needs. There is no evidence of a recent
hospitalization or significant changes in medication. There is no evidence of a need for intravenous
medications or wound care. The enrollee is ambulatory and has a supportive family and caregiver. The
enrollee's care needs appear to be custodial and - as a practical matter - can be provided by someone other than
a skilled nurse.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health care services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the member has not tried and failed zoledronic acid and the documentation does not support that zoledronic acid would likely be less effective. Our physician reviewer found the member does not have a history of osteoporotic fracture.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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat RFA of the lateral sacral branches.
You asked the Plan to pre-approve the repeat RFA. You say that you would like reconsideration because this procedure has been successful in the past. The Plan denied your request. The Plan says this treatment has not been proven as effective as standard treatment 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 repeat RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational because of the wide variation of efficacy in the peer-reviewed literature. 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 repeat RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat RFA of the lateral sacral branches.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an transthoracic echocardiograph (93306) provided November 6, 2019.
You asked the Plan to waive the copayment for the echocardiograph. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Outpatient Hospital services. You have been asked to pay a $200 copayment for the echocardiograph. The echocardiograph falls within the Outpatient Hospital 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 an transthoracic echocardiograph (93306) provided November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestem cell treatment.You asked the Plan to pre-approvethe stem cell treatment. You say that you would like reconsideration because this service is medically necessary and covered by the Plan.The Plan denied your request. The Plan says knee arthritis is not a covered condition for stem cell treatment.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 stem cell treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical peer reviewed literature indicates that stem cell therapy remains investigational for the treatment of knee osteoarthritis. Thesafety and effectiveness has not been fully established.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 stem cell treatment have not been met.Therefore, we decided that the Plan does not have to pre-approvestem cell treatment
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer.
You asked the Plan to pre-approve the Vertiflex Spacer. You say that you would like reconsideration because this is a Medicare covered benefit. The Plan denied your request. The Plan says the efficacy of this device has not been proven over traditional spinal fusion procedures.
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 Vertiflex Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of skin tags billed with CPT code 11200 for date
of service November 5, 2019.
You asked the Plan to pay for CPT code 11200. You say that the records provided support the CPT code in
dispute. The Plan denied your request. The Plan says the CPT code in dispute is not payable based on Medicare
rules for coverage.
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 11200 is removal of skin tags, multiple fibrocutaneous
tags, any area; up to and including 15 lesions.
We find that CPT code 11200 is not supported in the medical record. Specifically, the pathology report of the
nature of removed masses was not provided. While the services specifically represented by CPT code 11200
appeared to be provided on the date of service in dispute, the provider did not supply sufficient information to
support what was billed and for a determination as to whether criteria have been met for coverage. Based on
this information, we decided that Medicare rules for coverage of CPT code 11200 have not been met.
Therefore, we decided that the Plan does not have to pay for the removal of skin tags billed with CPT code
11200 for date of service November 5, 2019.
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 enrollee needs IRF care due to her fall risk secondary to a chronic history of seizures. You say that the enrollee's seizures occur at unpredictable frequencies. You say that the enrollee needs more frequent and a higher level of medical care than can be rendered at a skilled nursing facility or home health. You say that it is not safe for the enrollee to perform post-op rehabilitation at an outside rehabilitation facility. The Plan denied your request. The Plan says the records do not show that the criteria for coverage of IRF care have been met.
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 the enrollee is generally medically stable after lumbar spine surgery with no recent neurological or Orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week. There is no evidence of a need for acute rehab nursing care. Currently the enrollee is at minimal assist level and does not need an IRF admission. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427) provided
September 24, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayments should
be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for Ambulance Services.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance 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
an ambulance transport (A0427) provided September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral exam (D0150) provided March 4, 2020.You asked the Plan to pay forthe dental services. You say that 3 different dentists have told you that you need a deep cleaning on 2 top teeth. You haven't had your teeth properly cleaned for 2 years and is appealing the decision to deny coverage.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitations.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. This service is allowed once every 3 years. The records show that this service was provided October 8, 2018.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 forcomprehensive oral exam (D0150) provided March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures (dental code D5110).
You asked the Plan to pre-approve complete upper dentures. You say that the dentures you currently have are
partly broken and do not fit you, so you need a new set of dentures. The Plan denied your request. The Plan
says the denial of authorization for this service is correct, because complete upper dentures are only covered
once every 5 years and you were approved for complete upper dentures on June 22, 2018.
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 complete
upper dentures once every 5 years.
We looked at the file, Medicare rules, and the Plan's rules. You were approved for complete upper dentures
less than 5 years ago, therefore another set of complete upper dentures would not be covered by the Plan's
dental benefits at this time. Based on this information, we decided that the Plan's rules for coverage of complete
upper dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve complete
upper dentures (dental code D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic care (CPT 99201) you received on January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic care (CPT 99201) you received on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and dental consultation services.
You asked the Plan to pre-approve periodontal scaling and dental consultation services.. 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 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 periodontal scaling and dental consultation services.