Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient stay provided from November 14, 2019 to November 16, 2019 provided by the appealing provider.You asked the Plan to pay for the inpatient stay. You say that authorization was obtained but was cancelled. You feel since the services were provided that payment should be rendered.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regardingits decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. An attempt was made to confirm the circumstances surrounding the reported authorization and the Plan was not able to provide any information regarding the authorization and/or when or if it was cancelled. There was no other valid denial rationale other than the lack of authorization provided.Therefore, we decided that the Plan has to pay for an inpatient stay provided from November 14, 2019 to November 16, 2019 provided by the appealing provider.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 compression stockings identified with code A6533 that were issued on February 19, 2020.
You asked the Plan to pay for the compression stockings. You say that you require the stockings for venous insufficiency. The Plan denied your request. The Plan says the compression stockings are noncovered for all conditions.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 77002) provided to the enrollee on December 24, 2019.
You asked the Plan to pay for the services. You say that the denied charges should be reconsidered. The Plan denied your request. The Plan says an add-on code cannot be billed as a stand alone code.
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 77002 is "Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)." We find that CPT code 77002 is not supported in the medical record. Specifically, this code is considered an add-on code, and it is inappropriate to bill it separately in this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 77002) provided to the enrollee on December 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Endovenous ablation therapy of incompetent vein
(36475) and Stab phlebectomy of varicose veins (37766).
You asked the Plan to pre-approve these services. You say that this condition is very painful. The Plan denied
your request. The Plan says that you do not meet criteria for coverage of the requested procedures.
The Plan follows Medicare rules. Medicare rules say that treatment for Symptomatic Chronic Venous
Insufficiency or Varicose Veins (VV), in the absence of bleeding, phlebitis or skin necrosis, may be covered as
medically necessary when meeting all criteria and performed by appropriately trained personnel.
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 these services. Our reviewer says that
you do not meet criteria for coverage of Endovenous ablation therapy and Stab phlebectomy of varicose veins.
Our physician reviewer found that there is a lack of clarity with respect to the nature and degree of your
symptoms and overall plan. The is no documentation of what specifically is to be done and no documentation
of the incompetence of the valves or deep venous system. You have numerous co-morbidities that could
explain leg pain including multiple cardiovascular risk factors. Your BMI at most recent evaluation was over
the coverage limit. The documentation provided does not meet coverage criteria and does not support the
medical necessity of the procedures in question.
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve Endovenous ablation therapy of incompetent vein (36475) and Stab phlebectomy of
varicose veins (37766).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional home health skilled nursing 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 four visits can be approved.
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 the additional visits. Our reviewer says
that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's
condition and/or prevent deterioration. You do not have complex wound care or other skilled nursing needs. He
has been educated in disease management. Additional skilled nursing services are 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 two additional home health skilled nursing visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe computerized ophthalmic diagnostic imaging of the retina (92134) provided on November 19, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plandenied your request. The Plan says that the service was provided by an out of network provider, without prior authorization.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for this service by a contract provider. The file does not show that the Plan provided notice that this service would not be covered. Under Medicare rules, this means this service is considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe computerized ophthalmic diagnostic imaging of the retina (92134) provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and the prophylaxis (D1110)
provided on February 3, 2020.
You asked the Plan to pay for the dental services. You say that you were advised in December that the services
you were scheduled to receive in January would be covered. You also say that you were not advised that the
services cannot be used before 6 months. The Plan denied your request. The Plan says the dental services that
you received are not listed as covered under your Medicare Advantage plan.
Medicare generally does not cover dental services. The Plan offers a dental benefit under Medicaid, which is
out of our jurisdiction. For that reason, Medicaid coverage rules do not apply to our review in this case.
Though you have a dental benefit under your State Medicaid Plan, your Medicare plan does not cover these
services. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and the
prophylaxis (D1110) provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that you need your tooth to be capped. You say that you cannot afford to pay for a crown on your fixed income. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core build up (D2950) for tooth # 9.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. The Plan denied your request. The Plan says this drug is not Part B covered. The Plan also says that this is a self-administered drug.
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 Trulicity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal for tooth # 30.
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says tooth # 30 is non-salvageable. The Plan also says that the root canal is not medically necessary.
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 service 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 service. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided documentation shows a lesion on tooth # 30. The reviewer found that the lesion appears to be periodontal in origin, and not a lesion that would resolve with treatment by endodontic therapy. The reviewer found that endodontic treatment of a tooth that has a poor prognosis or is otherwise not readily restorable is not considered necessary or reasonable. Therefore the request for endodontic treatment on #30 is not medically necessary as the prognosis of the tooth is poor. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve a root canal for tooth # 30.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full titration study (95811).
You asked the Plan to pre-approve a full titration study. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 a full titration study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the records provided for review do not show that the member had a recurrence of obstructive sleep apnea (OSA) related symptoms. The records also indicate that the member was non-compliant with CPAP therapy (usage of 66% for 4 or more hours). The review has determined that the requested full titration study is not 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 full titration study have not been met. Therefore, we decided that the Plan does not have to pre-approve a full titration study (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a purifier for the enrollee.
You asked the Plan to pre-approve the purifier. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a purifier for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SPECT test provided on January 30, 2020.You asked the Plan to waive the copayment forthe SPECT test. You say that you were told there would not be a copayment if you had straight Medicare. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for Medicare-covered services in a non-preferred (hospital based) radiology facility. You have been asked to pay a $250 copayment for the SPECT test. The SPECT test falls within "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe SPECT test provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with accessories.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says durable medical equipment (DME) is not covered for use at a skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that these services are being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and inhalation of nitrous oxide/analgesia provided on December 5, 2019 by an OON provider.
You asked the Plan to pay for the extraction and inhalation of nitrous oxide/analgesia. You say that you made several calls to find an in-network provider, and on the last call you were told to choose an OON provider and the Plan would pay. The Plan denied your request. The Plan says the treating provider is a non-participating provider. The Plan also says that services performed by an OON provider are not covered because the enrollee's plan does not have OON 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 covered when they are received OON. The Plan confirmed that the contact history determined that the enrollee was given the name of an in-network provider, but there is no record of the enrollee being told to utilize an OON provider and services would be covered. Therefore, we decided that the Plan does not have to pay for the extraction and inhalation of nitrous oxide/analgesia provided on December 5, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a patient lift for the enrollee.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says there is no information related to being bed bound without the lift and needing more than one person to transfer.
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 lift. Our reviewer says that the requested lift is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee would be bed-confined without the lift. There is no evidence that transfer between a bed and chair/wheelchair/commode is required. The enrollee does not meet the criteria for this lift. 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 lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a patient lift for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from February 10, 2020 through February 13, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you shouldn't have paid the first copayment. The Plan denied your request. The Plan says you shouldn't have paid the first copayment.
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 $295 copayment per admission for each medically necessary inpatient stay. You have been asked to pay a $295 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were an inpatient for three days. 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 inpatient stay provided from February 10, 2020 through February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network. 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. 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 lab work provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proleukin, in combination with Interferon alfa-2B
Recombinant and BCG live intravesical vac.
You asked the Plan to pre-approve Proleukin. 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 medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Proleukin. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has a history of low grade superficial urothelial cancer (stage Ta) of the left kidney
who underwent left nephroureterectomy in 2011. The enrollee underwent TURBT/bladder biopsy October 31,
2019 revealing carcinoma in situ (CIS). The enrollee had a biopsy April 1, 2020 and had a small papillary
bladder tumor. The enrollee received a 6 week course of intravesical BCG in 2019. The requested use of
Proleukin, in combination with Interferon alfa-2B Recombinant and BCG live intravesical vac is not FDA approved
for the enrollee's diagnosis and is considered experimental/investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Proleukin have not been met. Therefore, we decided that the Plan does not have
to pre-approve Proleukin, in combination with Interferon alfa-2B Recombinant and BCG live intravesical vac.