Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).

You asked the Plan to pre-approve a shower chair. You say that this is necessary for the enrollee's safety. The
Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair 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 shower chair (E0240).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a participating provider on July 26, 2020, to July 27, 2020.

You asked the Plan to waive the copayment for emergency room services. You say that you were admitted, and this copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85 copayment for emergency care.

You have been asked to pay an $85 copayment for emergency room services. Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient hospital services. Emergency room services fall 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 emergency room services provided by participating provider on July 26, 2020, to July 27, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the diagnostic mammography. We decided that the
Plan does not have to waive the cost share for the biopsy.

You asked the Plan to waive the cost share for the biopsy and diagnostic mammography. You say that you
would like the Plan to reconsider your request. The Plan says that the correct cost share has applied per your
contract with the Plan.

We decided that the Plan has to reduce the cost share for the diagnostic mammography.

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 $10
copayment for the diagnostic mammography. Therefore, we decided that the Plan has to reduce the cost share
for the diagnostic mammography.

We also decided that the Plan does not have to waive the cost share for the biopsy.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for the biopsy. You have been asked to pay a $225 copayment for the outpatient surgery, which is
less than the contracted $250 copayment amount. Therefore, we decided that the Plan does not have to waive
the cost share for the biopsy.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xerava.

You asked the Plan to pre-approve Xerava. The Plan denied your request. The Plan says the off-label use for the drug is not medically accepted.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the documentation is safe and effective and otherwise reasonable and necessary for this enrollee. Based on this information, we decided that Medicare rules for coverage of Xerava have not been met. Therefore, we decided that the Plan does not have to pre-approve Xerava.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional OT home care visits.

You asked the Plan to pre-approve the additional OT visits. You say that you were supposed to have 4 more
OT visits, which you would still like to receive because it has been helping you. The Plan denied your request.
The Plan says the documentation has failed to indicate your continued need for the specialized judgement,
knowledge, and skills of an occupational therapist.

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 OT visits. Our reviewer
says that the additional requested therapy is not generally accepted as specific and effective therapy for your
condition beyond what was approved by the Plan. Our physician reviewer found you have had prior OT and the
records do not demonstrate that the unique skills of a professional therapist are required to provide treatment
safely and effectively, or that the services can be safely and effectively performed only by a therapist, or under
the supervision of a therapist. Our reviewer found that you have been instructed in a home exercise program
and safety. Our physician reviewer also found that the requested services are not part of a maintenance
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 OT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 4 additional OT home care visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for specialist services provided by a participating provider on November 18, 2020.

You asked the Plan to waive the coinsurance for an injection and copayment for specialist services. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network and a $25 copayment for physician/practitioner services/in-network/specialist.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $25 copayment for specialist services. The total allowed amount is $1,194. The amount you are being asked to pay for an injection is $238.80 ($1,194 x 20% = $238.80). The total amount you are being asked to pay is $263.80 ($238.80 + $25 = $263.80). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and specialist services falls within the physician/practitioner services/in-network/specialist 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 coinsurance for an injection and copayment for specialist services provided by a participating provider on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical notes submitted by the doctor do not show any of the covered conditions.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of any conservative therapy, such as physical therapy, chiropractic therapy, medication trials, or acupuncture. There is no imaging submitted for review. Therefore, the request is deemed 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 15, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. Per LCD L36358, the requested testing is non-covered. 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 cardiovascular risk assessment panel provided on September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services provided from September 30, 2020 to October 30, 2020.

You asked the Plan to waive the copayments for the ambulance services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received ambulance services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per the enrollee's contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for Ambulance services. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received ambulance services from September 30, 2020 to October 30, 2020. The enrollee has been asked to pay a $150 copayment for each ambulance service provided from September 30, 2020 to October 28, 2020. The enrollee has been asked to pay a $107.88 copayment for the ambulance services provided on October 30, 2020, which is less than the contracted $150 copayment amount. The ambulance services fall within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 

You were requesting a waiver of copayments for ambulance services provided through November 6, 2020. The file shows the enrollee met her out-of-pocket maximum on October 30, 2020. No copayment applied to any services rendered to the enrollee after October 30, 2020.

Therefore, we decided that the Plan does not have to waive the copayments for the ambulance services provided from September 30, 2020 to October 30, 2020.

Your complaint about the Plan's transportation benefit not being utilized is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing (U0004) provided on October 23, 2020, through October 27, 2020.

You asked the Plan to pay for the Covid-19 testing. You say that you would like reconsideration because this service was billed with the appropriate modifier. The Plan denied your request. The Plan says CPT code U0004 has been billed incorrectly per CMS guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code U0004-CS is not supported in the medical record. Specifically, per CMS, it is not appropriate to bill modifier CS with CPT code U0004. Based on this information, we decided that Medicare rules for coverage of the Covid-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Covid-19 testing (U0004) provided on October 23, 2020, through October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September
14, 2020.

You asked the Plan to pay for the lumbar sacral orthosis (L0650). You say that the lumbar sacral orthosis
provided on September 14, 2020 was medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the provided lumbar sacral orthosis provided on September 14, 2020.

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 pay for the lumbar sacral orthosis (L0650). Our
reviewer says that the enrollee does not meet criteria for the provided lumbar sacral orthosis provided on
September 14, 2020. Our physician reviewer found the enrollee's chief complaint was lower back pain. The
available documentation in the case file does not support that the requested lumbar-sacral orthosis (LSO) was
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established
by the LCD. An appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for an LSO have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as
there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation
of a credible physical examination of the back.

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 lumbar sacral orthosis (L0650) have not been met. Therefore, we decided
that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services from an oral surgeon.

You asked the Plan to pre-approve these services. You say that you are in pain and need to see an oral surgeon as soon as possible. The Plan denied your request. The Plan says the services are not covered.

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 supplemental dental benefits from a general dentist only. 

We looked at the file and the Plan's rules. You are requesting services from an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve services from an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100mg/5ML Etoposide.

You asked the Plan to pre-approve Etoposide. You say that you would like reconsideration because this drug is medically necessary to treat the member's condition. The Plan denied your request. The Plan says the dispensing plan meets criteria for Part D coverage.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve 100mg/5ML Etoposide.

Benefits for Etoposide 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.

You asked the Plan to pre-approve twenty-four (24) additional routine transportation trips. You say that you cannot take public transportation. The Plan denied your request. The Plan says that your benefit only allows 24 trips for this service.

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 twenty-four (24) trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of twenty-four (24) routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF level of care. The Plan denied your
request. The Plan says the denial of authorization for IRF care is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports
a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy
program provided at an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance (64624) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this type of surgery/procedure is considered experimental and/or unproven.

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 requested services are not considered medically reasonable and necessary in this case. This is considered an experimental/investigational procedure that is the subject of on-going clinical trials. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.

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 destruction by neurolytic agent, genicular nerve branches including imaging guidance (64624) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).

You asked the Plan to pre-approve the dental items. You say that your dentures are broken. You also say that you need new ones. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.

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 and dentures are listed a covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on July 30, 2018, less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).