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

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on February 11, 2020.
You asked the Plan to pay for these services. You say that the Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that the SNF must submit ALL Medicare claims for ALL the services that its residents receive under Part A. We looked at the file and Medicare rules. The file shows that procedure code R0070 was billed with place of service code 31 for a SNF. Payment for these services is included in the SNF consolidated billing. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on February 11, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CTA of the brain and neck for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that according to the guidelines, you would need to have a carotid duplex ultrasound performed prior.The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the scan. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found the CTA of the chest on 7/15/20 demonstrates severe atherosclerotic narrowing of the origin of the left common carotid and left subclavian arteries. It is medically necessary to evaluate the integrity of the carotid and vertebral arteries distal to the origin of these vessels including the intracranial circulation to determine if any intervention may be necessary. The policy concerning ultrasound screening beforehand should not apply in this case due to the documentation of severe narrowing of the origins of the left common carotid and left subclavian arteries. Note the left vertebral artery commonly arises from the left subclavian artery.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 scan have been met.Therefore, we decided that the Plan has to pre-approve CTA of the brain and neck for the enrollee.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has recurrent strokes with no new neurological symptoms. The requested testing is used to delineate neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders and or an assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. The records do not support the increased amount of testing based on no new neurologic symptoms and the presence of strokes. The testing is therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Irinotecan/Oxaliplatin/Zirabev drug regimen for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires that the cancer has not grown or spread while on therapy with irinotecan.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the records provided showed that the enrollee had tried FOLFIRI which includes irinotecan and 5-fluorouracil, however, her cancer appeared to have progressed on this therapy. The enrollee would not be expected to have benefit from using irinotecan again to justify this request which includes this medication. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Irinotecan/Oxaliplatin/Zirabev drug regimen for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora PostitronEmission Tomography (PET) scan provided February 7, 2020.You asked the Plan to pay forthe PET scan. You say that the services were medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 78815 is not supported in the medical record. Specifically, the claim did notinclude a valid primary diagnosis code for this CPT code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pay fora Postitron Emission Tomography (PET) scan provided February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea raised toilet seat.You asked the Plan to pre-approvea raised toilet seat. You say that you need the requested item because you have problems with your knees and hips. You say that these problems make it hard for you to sit all the way down and get back up without hurting yourself. You asked the Plan to reconsider providing coverage.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approvea raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound repair surgery provided on October 8, 2019.
You asked the Plan to waive the copayment for the wound repair surgery. You say that you were charged two copayments for the same service. 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 $30 copayment per visit to an in-network specialist for Medicare-covered services. You have been asked to pay a $30 copayment for the wound repair surgery. The wound repair surgery falls within the "Physician services, including medical and surgical services in a physician's office" benefit category. The record shows you were billed by the physician for the surgery service.
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 wound repair surgery provided on October 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 36 additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is needed to get to and from medical
appointments. The Plan denied your request. The Plan says the service is covered benefit, but the enrollee has
met the plan limits which have been set in the subscriber agreement.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 36 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you additional trips cannot be covered, as the maximum is 36 per year. Therefore, we decided that the Plan
does not have to pre-approve 36 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950) and bone replacement graft (D7953). You asked the Plan to pre-approve the core buildup (D2950) and bone replacement graft (D7953). You say that this is the recommended treatment plan.The Plan denied your request. The Plan says the 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.Therefore, we decided that the Plan does not have to pre-approve the core buildup (D2950) and bone replacement graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe home ventilator, with non-invasive interface (E0466).You asked the Plan to pre-approvethe ventilator. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the clinical information did not support the medical necessity for this service.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.   Our physician reviewer found this enrollee has obstructive sleep apnea and morbid obesity. She does not have neuromuscular disease or thoracic restrictive disease, and the record provides no evidence for chronic obstructive pulmonary disease. Therefore,she does not have a covered diagnosis. There is no ABG done while in a stable state. There is no evidence of failure of BiPAP. The enrollee may have obesity-hypoventilation syndrome, which is treated with CPAP or BiPAP. A home ventilator is 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 ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvethe home ventilator, with non-invasive interface (E0466).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study (95805, 95810).You asked the Plan to pre-approvea sleep study. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has had a recent sleep study and does not have new symptoms.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 sleep study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has excessive daytime sleepiness and hypersomnolence, which may result from a combination of mild obstructive sleep apnea (OSA), restless leg syndrome, and medications that enhance sleepiness and alter REM sleep. The patient does not have symptoms suggestive of narcolepsy, so there doesnot appear to be an indication for multiple sleep latency test, and this test is therefore not medically necessary. The diagnosis of OSA has already been established on attended polysomnography (PSG) approximately 1 year ago. A repeat PSG is considered 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 a sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approvea sleep study (95805, 95810).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forPart B drugs and an injection procedure provided on March 30, 2020.You asked the Plan to waive the coinsurance forPart B drugs and specialist services. You say that you feel that this cost-share is very high.The Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct.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 35% coinsurance for out-of-network Part B drugs and specialist services. The allowed amount of the claim is $879.72, resulting in a coinsurance obligation of $307.90.You have been asked to pay 35% coinsurance for Part B drugs and specialist services. Part B drugs and specialist services fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 coinsurance forPart B drugs and an injection procedure provided on March 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTecentriq, with Gemcitabine HCL and Cisplatin.You asked the Plan to pre-approveTecentriq, Gemcitabine HCL and Cisplatin. You say that the requested Tecentriq, Gemcitabine HCL and Cisplatin is medically necessary.The Plan denied your request. The Plan says the requested Tecentriq, Gemcitabine HCL and Cisplatin 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 Tecentriq, Gemcitabine HCL and Cisplatin. Our reviewer says that the requested Tecentriq, Gemcitabine HCL and Cisplatin is not medically necessary. Our physician reviewer found the enrollee is with concomitant metastatic IIIb squamous lung cancer with concern for metastatic urothelial cancer with mets to the lung that contains urothelial cells. The requested use of the drugs is not FDA-approved for the enrollee's diagnosis. It is not clearly a urothelial cancer and if it were, tecentriq is not indicated to be used in combination with cisplatin and gemcitabine.We looked at this physician's review, the file, and Medicare rules.Based on this information, we decided that Medicare rules for coverage of Tecentriq, Gemcitabine HCL and Cisplatin have not been met.Therefore, we decided that the Plan does not have to pre-approveTecentriq, with Gemcitabine HCL and Cisplatin
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on February 23, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed
incorrectly.
The Plan must follow Medicare rules. Medicare rules say that testing must be reported with one
unit of CPT 81479 and the appropriate Code.
We looked at the file and Medicare rules. The requested testing was billed with multiple CPT
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX ZCode.
Based on this information, we decided that Medicare rules for coverage of the testing have not been met.
Therefore, we decided that the Plan does not have to pay for the testing provided on February 23,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture (D5110) and mandibular partial denture (D5214) provided on March 11, 2020.You asked the Plan to pay forthe complete maxillary denture and mandibular partial denture. You say that you are appealing the decision on your policy change.The Plan denied your request. The Plan says these services are not covered by the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not haveto pay forthe complete maxillary denture (D5110) and mandibular partial denture (D5214) provided on March 11, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for dental services provided on November 4, 2019 and
November 18, 2019.
You asked the Plan to pay more for the dental services. You say that incorrect information was given to the
dentist. You say that it will be hard to make the payment. The Plan denied your request. The Plan says the
claims processed with the in-network coinsurance for crowns.
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 is only obligated to pay 30%
toward your covered benefits.
Date of Service Service Allowed Amount Coinsurance Member Liability
November 4, 2019 Retainer Crown $831 70% $581.70
November 4, 2019 Retainer Crown $831 70% $581.70
November 4, 2019 Pontic $843 70% $590.10
November 4, 2019 Core Buildup $212 70% $148.40
November 4, 2019 Gingivectomy or
Gingivoplasty
$40 70% $28
November 4, 2019 Gingivectomy or
Gingivoplasty
$40 70% $28
November 18, 2019 Periodontal Scaling
and Root Planing
$143 70% $100.10
November 18, 2019 Periodontal Scaling
and Root Planing
$143 70% $100.10
TOTAL: $2,158.10
Therefore, we decided that the Plan does not have to pay more for dental services provided on November 4,
2019 and November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for sensorimotor examination (92060) ophthalmological eye exam (92065) laboratory, developmental and behavioral screening and testing. (96112) provided September 26, 2019 to October 16, 2019.
You asked the Plan to waive the copayment for the vision services. You say that This dispute concerns the $25 charges. The billing office managers reassured you that there would be no charges passed on to you and no office visit copays. The Plan denied your request. The Plan says the claims were processed and the correct copayment was applied per the plan benefits.
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 $25 copayment for each specialist's office visit. You have been asked to pay $100. You were charged $25 copayment for dates of service 09/26/2019, 10/02/19, 10/09/2019, 10/16/2019. The vision services fall within the Vision 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 sensorimotor examination (92060) ophthalmological eye exam (92065) laboratory, developmental and behavioral screening and testing. (96112) provided September 26, 2019 to October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 23,
2019.
You asked the Plan to pay for the periodontal maintenance. You say that you have been a patient at this office
for many years, and have had this procedure before. The Plan denied your request. The Plan says this service is
not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910) provided on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 6, 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 prior authorization was not obtained. The Plan says that
they were unable to discover any evidence of an established relationship between the member and the ordering
physician.
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 August 6, 2019 by an out of
network (OON) provider.