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

We decided that the Plan does not have to waive the copayment for outpatient lab work provided by an in-network facility on October 31, 2019.
You asked the Plan to waive the copayment for outpatient lab work. You say that this was part of your annual physician exam. The Plan denied your request. The Plan says the lab work that was provided goes beyond an annual wellness exam; therefore, the correct copayment has been 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 $20 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $20 copayment for outpatient lab work. Outpatient lab work falls within the outpatient diagnostic tests/laboratory tests 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 outpatient lab work provided by an in-network facility on October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services.
You asked the Plan to pay for the transportation services. You say that the Plan should cover the wheelchair van transport services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 18, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on February 18, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on November 18, 2019.
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 that the diagnosis was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has neuroendocrine cancer for which a dota-tate PET scan was ordered. This scan is approved for the evaluation of neuroendocrine cancer and was reasonable and 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 been met. Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on November 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services on December 11, 2019.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the outpatient hospital service charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital services. You have been asked to pay a $250 copayment for outpatient hospital services. Outpatient hospital services fall 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 outpatient hospital services on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Hip (73721).
You asked the Plan to pre-approve the MRI.. You say that the MRI is medically necessary. The Plan denied your request. The Plan says the MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that rules for coverage are not met. Our physician reviewer found the enrollee has no complaints of back, hip or knee pain. Examination notes no lower extremity neurologic deficits. It is unclear how MRI of the hip would change the enrollee's diagnosis or treatment. 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 MRI. have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Hip (73721).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation home from the skilled nursing facility.
You asked the Plan to pre-approve the services. You say that you do not have any way to get home from the facility, because you were brought in on a stretcher, and you are unable to walk. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation home from the skilled nursing facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator.
You asked the Plan to pre-approve an osteogenesis stimulator. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an osteogenesis stimulator is covered when one of the above 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 pre-approve an osteogenesis stimulator. Our reviewer says that the requested osteogenesis stimulator is not medically reasonable and necessary. Our physician reviewer found The review indicates that the enrollee is a 73-year-old female with ongoing neck pain and a possible old odontoid fracture without instability which required a single level spinal surgery (C1-2 cervical arthrodesis). The enrollee does not meet any of the LCD coverage criteria for coverage of the requested Osteogenesis Stimulator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant services.
You asked the Plan to pre-approve attendant services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says attendant services are considered custodial care and are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Custodial care is not covered. We looked at the file and Medicare rules. In this case, attendant services are being requested. Attendant services are considered custodial care, which includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial care is not covered under Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of attendant services have not been met. Therefore, we decided that the Plan does not have to pre-approve attendant services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a thoracic epidural steroid injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that this is 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 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 the injection. Our reviewer says that the requested epidural steroid injection is considered medically reasonable and necessary in this case. Our physician reviewer found that this is standard therapy for post-herpetic neuralgia. The Plan is relying on the guidance for musculoskeletal and not on the guidance for post-herpetic neuralgia. The requested injection is 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 injection have been met. Therefore, we decided that the Plan has to pre-approve a thoracic epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that it is the nursing facility's responsibility to obtain authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 15, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe emergency room visits provided from October 12, 2019 to October 18, 2019.You asked the Plan to waive the copayments forthe emergency room visits. You say that you were not under observation care. You say you were an inpatient at the time the services were rendered. The Plan denied your request. The Plan says you have been charged the correctcost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copaymentfor each Medicare covered emergency room visit. You have been asked to pay a $65 copayment for each of the emergency room visits. The emergency room visits fall within the "Outpatient hospital services" benefit category. The medical records show you were admitted as an outpatient during each of your emergency room visits.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 inthe Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe emergency room visits provided from October 12, 2019 to October 18, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve surgical bone reshaping on 1-3 teeth, in the upper left quadrant for
the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says that there is no current evidence of significant bone loss in the upper left
quadrant.
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 the dental
services when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says
that the requested dental services are medically reasonable and necessary. Our physician reviewer found the
enrollee presents with a history of scaling and root planing within the past year as well as periodontal
maintenance. The request is being made for osseous recontouring (D4261) in the upper left quadrant. A close
review of the x-ray reveals a defect on the mesial of #14, presumably where the 6mm pocket was measured,
this after fairly recent scaling and root planing then a maintenance appointment. There appears to be an open
contact between #13 and #14 which likely is fueling the pocket and bone defect as it is allowing for food
impaction. Bone recontouring will allow for reduction of the pocket and provide an improved environment for
better cleansability of the affected area. The procedure requires a full thickness flap and removal of bone to
achieve the required result. The radiographic findings and periodontal charting do support the need for the
requested procedure given the recent past history of periodontal scaling and root planing and noted osseous
defect on the mesial of #14 in the area of the 6mm pocket measurement. The requested treatment is reasonable
and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to
pre-approve surgical bone reshaping on 1-3 teeth, in the upper left quadrant for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says additional sessions are not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no indication that prior physical therapy has served to provide sustained, significant improvement in pain and/or function. There is no indication that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 sensor for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. 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 and supplies are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. 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 pre-approve a Dexcom G6 sensor for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 11, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 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 thatthe Plan does not have to pay forthe subsequent nursing facility care (99308) rendered by the out of network (OON) provider on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you need this because you check your glucose every day. The Plan denied your request. The Plan says that you only receive one insulin injection a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).