Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve angiography and revascularization.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary with a normal ABI and no evidence of claudication or limb ischemia.

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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, you have hypertension, diabetes and coronary artery disease with stent placement. You have bilateral foot numbness as well as claudication. The arterial duplex is suggestive of peripheral vascular disease. ABI in a diabetic patients is unreliable. The requested service is medically reasonable and necessary for the enrollee as defined by Medicare rules.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve angiography and revascularization.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet light therapy system and ankle foot orthosis rendered on January 21, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the 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 ultraviolet light therapy system and ankle foot orthosis rendered on January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of 88112 and 88305 provided on August 31, 2020.

You asked the Plan to pay for additional units of 88112 and 88305. You say that these services were medically necessary. The Plan denied your request. The Plan says the record does not support additional units.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that an additional 4 units of CPT code 88112 for a total of 8 units and 3 of 88305 for a total of 6 units are not supported in the medical record. The medical record only supports 4 units of CPT code 88112 and 3 of 88305, which were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of additional units of 88112 and 88305 have not been met. Therefore, we decided that the Plan does not have to pay for additional units of 88112 and 88305 provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 30, 2021.

You asked the Plan to pay for the orthosis. You say that temporary coverage for all telemedicine modalities are allowed. The Plan denied your request. The Plan says the documentation did not include a valid proof of delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain valid proof of delivery, or relevant medical records which support medical necessity for the orthosis. There are insufficient medical records to substantiate the knee orthosis. There is no record of a previous physical exam, testing, or imaging to confirm the enrollee's diagnosis or condition. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided February 22, 2021 to February 24, 2021.
You asked the Plan to waive the copayment for the emergency visit. You say that on February 22 there was no other choice. Your condition was complicated and required hospitalization. It is not your intent to run up medical bills. The Plan denied your request. The Plan says since the hospital did not admit you, the claim was processed with the correct emergency copayment applied per the Evidence of Coverage.
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 $120 emergency room copayment. You have been asked to pay $120 copayment for the emergency visit. The emergency visit falls within the Emergency care 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 the emergency department visit provided February 22, 2021 to February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 11, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub rail (E0242) and a toilet rail (E0243).
You asked the Plan to pre-approve the grab bars. You say that the items are medically necessary. The Plan denied your request. The Plan says these items are self-help devices and not medical in nature.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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 bathtub rail (E0242) and a toilet rail (E0243).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 20, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 42 of the Plan's 2021 EOC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on March 21, 2021.
You asked the Plan to pay for the provided items. You say that the device is medically necessary. The Plan denied your request. The Plan says the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the provided items have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on March 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus IBD sgi Diagnostic test rendered on February 4, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the Prometheus IBD sgi Diagnostic test is denied as not medically necessary. We looked at the file and Medicare rules. The testing at issue is the Prometheus IBD sgi Diagnostic test. This test is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the Prometheus IBD sgi Diagnostic test rendered on February 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).

You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this IMRT will not be helpful to providing palliative care.

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 IMRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 70-year old male with an abnormal magnetic resonance imaging (MRI) scan showing a small pancreatic lesion, likely adrenal adenoma, renal cystic lesion, and a renal cortical enhancing lesion. There is no documentation of a cancer diagnosis, what will be treated with radiation, or why IMRT would be necessary in lieu of other forms of radiation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.

You asked the Plan to pay for the 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 had network providers available who could have provided 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 services provided by an out-of-network provider on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept 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 experimental and investigational procedures are not covered by Medicare.
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 the requested procedure remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of the device. 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 Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 0202U provided on December 8, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The laboratory test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 0202U provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150),
prophylaxis (D1110), topical fluoride application (D1208), bitewing x-rays (D0274) and intraoral x-rays
(D0220 and D0230) provided on January 25, 2021 and the crown (D2740) provided on March 3, 2021.
You asked the Plan to pay more for the comprehensive oral evaluation (D0150), prophylaxis (D1110), topical
fluoride application (D1208), bitewing x-rays (D0274), intraoral x-rays (D0220 and D0230) and crown
(D2740). You say that you understand you would not receive the full amount using an out-of-network doctor,
but the amount received was an insult. You say that you took the dental policy thinking you would get
assistance with medical expenses. The Plan denied your request. The Plan says the claims processed correctly.
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 Plan paid their share of the cost for
the comprehensive oral evaluation, prophylaxis, topical fluoride application, bitewing x-rays and crown. The
intraoral x-rays are not a covered benefit and you are responsible for any amount greater than the amount paid
by the Plan for services received from an out-of-network provider. Therefore, we decided that the Plan does not
have to pay more for the comprehensive oral evaluation (D0150), prophylaxis (D1110), topical fluoride
application (D1208), bitewing x-rays (D0274) and intraoral x-rays (D0220 and D0230) provided on January
25, 2021 and the crown (D2740) provided on March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the information submitted doesn't meet the Plan's medical necessity guidelines for coverage.
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 Hyalgan. Our reviewer says that Hyalgan (J7321) is not approved as step criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan.

You asked the Plan to pre-approve Zioptan. You say that the enrollee has had an improvement of symptoms, is stable on Zioptan, and needs to continue treatment. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.

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 Zioptan.

Benefits for Zioptan may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the anesthesia for procedures on the eye; lens surgery (00142) provided on March 17, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.

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 $750
annual deductible. Additionally, you must pay a $125 copayment after the deductible is met for each outpatient
surgery and/or services at an ambulatory surgical center or outpatient hospital facility.

You have been asked to pay a $24.41 deductible applied for the anesthesia provided as you has not previously
met the annual deductible. 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 deductible for the anesthesia for
procedures on the eye; lens surgery (00142) provided on March 17, 2021.