Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance forthe therapeutic injection. We decided that the Plan does not have towaive the coinsurance forthe denosumab injection. You asked the Plan to waive the coinsurance forthe denosumab injection and therapeutic injection. You say that you thought this service was fully covered. You say that you cannot afford this expense.The Plan says that the coinsurance applied correctly.We decided that the Planhas to waive the coinsurance forthe therapeutic injection. The therapeutic injection is considered a physician service, not a Part B drug. Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for physician services when billed by a hospital.This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the coinsurance forthe denosumab injection and therapeutic injection. We also decided that the Plandoes not have to waive the coinsurance forthe denosumab injection.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 20% coinsurance for Medicare Part B covered chemotherapy drugs and other Part B covered drugs.Therefore, we decided that the Plan does not have to waive the coinsurance forthe denosumab injection.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 toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventative procedure (D1999) and topical application of fluoride varnish (D1206) provided on June 10, 2020.You asked the Plan to payforthe unspecified preventative procedure and topical application of fluoride varnish. You say that the services requested should be covered under your Plan's supplemental benefit.The Plan denied your request. The Plan says these services are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Although you do receive coverage fortwo fluoride treatments per year, the specific coded fluoride treatment you received, D1206, is not covered per the Plan's EOC. Therefore, we decided that the Plan does not have to pay forthe unspecified preventative procedure (D1999) and topical application of fluoride varnish (D1206) provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services you provided on June 11, 2020. Records show that you are an out of network (OON) provider.You asked the Plan to pay forthe medical services. You did not provide an argument for coveragebut you provided medical records and requested that this claim be reprocessed.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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.You are not a network provider with the Plan. 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 forthe medical services you provided on June 11, 2020. Records show that you are an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 15, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also coversattending physician services and all care unrelated tothe terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted laparoscopy procedure services coded 50949 and the cystourethroscopy services coded 52332 provided on May 6, 2020.You asked the Plan to pay forthe unlisted laparoscopy procedure services and the cystourethroscopy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 50949 and 52332 is not supported in the medical record. Specifically, the operative report did not include documentation of an unlisted laparoscopic ureter procedure; therefore, code 50949 cannot be verified. The operative report did not include documentation of cystourethroscopy with insertion of indwelling ureteral stent (Gibbons or double-J type); therefore, code 52332 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted laparoscopy procedure services and the cystourethroscopy services have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted laparoscopy procedure services coded 50949 and the cystourethroscopy services coded 52332 provided on May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EEG provided on August 4, 2020.
You asked the Plan to waive the copayment for the EEG. You say that the amount of the bill is high, and you don't understand why. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each covered diagnostic procedure or test at a network outpatient facility. You have been asked to pay a $150 copayment for the EEG. The EEG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The EEG is considered a diagnostic test that was provided by the hospital. 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 EEG provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from December 17, 2020, forward.You asked the Planto pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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-approveinpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 17, 2020, forward as this patient was not shown to be a danger to themselves or others. The patient was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any acute threats the safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from December 17, 2020, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided.

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.

The Plan denied your request. The Plan says approval was not obtained for the services.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was not too unstable for placement in Observation from the ED. The enrollee was hemodynamically stable. The abnormal ABG was of unclear significance with improvement on repeat study. Observation status was indicated for this enrollee, denial upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ice therapy machine (E1399).You asked the Plan to pay forthe ice therapy machine. You say that you require the machine and think it should be paid for.The Plan denied your request. The Plan says the item does not meet thedefinition of durable medical equipment and is therefore noncovered.The Plan must follow Medicare rules. Medicare does not cover any form of ice machine, ice or cold therapy unit or device for home use and does not meet the definition of being DME.Therefore, we decided that the Plan does not have to pay foran ice therapy machine (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 30, 2019, by an OON provider.You asked the Plan to pay fornursing facility care and a debridement procedure. You say that these services were medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.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 of pre-approved care.The requested provider inthis 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 forthe medical services provided on October 30, 2019, by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 10, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of acovered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection procedure for sacroiliac (SI) joint,
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT
Code 27096).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the records do not show that the member has had a diagnostic sacroiliac shot that gave
them at least a 75 percent reduction in pain.
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 services. 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 documentation of the effectiveness of the prior SI joint injection. Therefore, the
request is considered 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 the services have
not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for
sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when
performed (CPT Code 27096).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveunlisted procedure, dentoalveolar structures (CPT Code 41899), impression and custom preparation; oral surgical splint (21085), graft, bone; mandible (includes obtaining graft) (21215) and graft, bone; nasal, maxillary or malar areas (includes obtaining graft) (21210).You asked the Plan to pre-approvethe dental services. You say that this request should not belooked at under the member's dental benefits because they are all medical services.The Plan denied your request. The Plan says the services are not covered by the medical benefits.Medicare generally does not cover dental services. The Plan follows thesame rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approveunlisted procedure, dentoalveolar structures (CPT Code 41899), impression and custom preparation; oral surgical splint (21085), graft, bone; mandible (includes obtaining graft) (21215) and graft, bone; nasal, maxillary or malar areas (includes obtaining graft) (21210).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forscanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided February 19, 2020.You asked the Plan to pay forthe diagnostic services. You say that you areappealing the denial. You are tired of this and the claim was billed with the correct code.The Plan denied your request. The Plan says that services are not covered benefit under the routine supplemental vision benefit and needs to be submitted to medical plan for consideration.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided from an in-network primary care physician's office, specialist's office, urgent care center, outpatient hospital and freestanding radiological facility.We looked at the file and the Plan's rules. The plan contract on page 69 specifically says that the plan covers diagnostic procedures and tests, advanced imaging services, basic radiological services and diagnostic mammography. Based on this information, we decided that the Plan's rules for coverage of the diagnostic services have been met.Therefore, we decided that the Plan has to pay forscanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided February 19,2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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 pre-approve right sacroiliac lateral radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not meet the criteria.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational because of the wide variation in efficacy is the peer reviewed literature. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve right sacroiliac lateral radiofrequency ablation for the enrollee.