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

We decided that the Plan has to pre-approve Microwave Ablation (50592) of a Lesion.
You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ablation procedure. Our reviewer says that the ablation procedure is medically appropriate in this case. Our physician reviewer found the lesion is suspicious for malignancy and lack of growth over three months does not mean this is not cancerous. Biopsy has similar risk to curative procedure and runs risk of inducing spread of tumor, if malignant. Ablation is the standard of care in this circumstance. 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 ablation procedure have been met. Therefore, we decided that the Plan has to pre-approve Microwave Ablation (50592) of a Lesion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitza capsules.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Amitza capsules.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 27, 2019.

You asked the Plan to waive the copayment for a specialist visit. You say that you refused an ultrasound and should not be charged for one. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for each specialist visit. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 21.
You asked the Plan to pre-approve the dental service. You say that the enrollee does not have subcrestal caries.
You say that what is being seen in the x-ray is radiographic artifact. You say that after doing a clinical exam,
the enrollee had recurrent decay around his old composites. You also say that the enrollee is an ideal candidate
for a crown. The Plan denied your request. The Plan says that there is evidence of subcrestal decay and this
finding results in poor long term prognosis for this tooth.
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 medically necessary. Our physician reviewer found the enrollee's dental record and x-rays
that were provided indicate recurrent caries around the large composite restoration and no subcrestal caries.
The reviewer also found that a crown restoration is reasonable and necessary due to the significant breakdown
of the coronal structure.
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 been met. Therefore, we decided that the Plan has to
pre-approve a crown (D2750) for tooth # 21.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a rib x-ray (71045) provided on November 30, 2018.
You asked the Plan to pay for the rib x-ray. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says this claim was submitted without a modifier to consider
a separate procedure.
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, we have confirmed that code the rib
x-ray has a bundled relationship with code 71100 and cannot be paid as billed. CPT code 71045 has not been
billed with an appropriate to indicate a separate service has been rendered. This code cannot be paid as a
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for a rib x-ray (71045) provided on November 30, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 12, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 referring provider 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 the medical services provided on October 12, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September
23, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you did not know you would be
charged to remove the polyps during the colonoscopy. You say this is a great financial hardship. 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 $350
copayment per day for outpatient procedures and services, including but not limited to diagnostic and
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical
center.
You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient hospital services" benefit category. The record shows polyps were removed which makes the
colonoscopy diagnostic in nature.
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 colonoscopy provided on September 23, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xgeva (denosumab) for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy is required for this drug.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found there is no evidence of a trial and failure of Zoledronic acid. However, the documentation in the medical record supports that this drug would likely have adverse effects for the enrollee in this case. The use of Zoledronic acid is not recommended in the setting of multiple myeloma and bone involvement when the creatinine clearance is less than 30 mL/min.

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 drug have been met. Therefore, we decided that the Plan has to pre-approve Xgeva (denosumab) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica capsules.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied
your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered
by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lyrica capsules.
Benefits for self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 Freestyle Libre 14-day sensor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee clearly does not meet the criteria provided as they do not use insulin. While it is medically reasonable for enrollees who do not use insulin to check blood glucose (BG) levels in some situations (eg. if a1c is above goal to help determine when BG is high, if enrollee is having low BG or is on a medication that can cause low BG like glipizide), we are given no information here to justify why the enrollee needs to check BG. 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 Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not urgent and were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Irinotecan Liposome (Onivyde) for the enrollee.
You asked the Plan to pre-approve Onivyde. You say that the enrollee is unable to safely receive Fluorouracil. The Plan denied your request. The Plan says the use of Onivyde was associated with more severe toxicity than with combination therapy.
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 Onivyde. Our physician reviewer found that the enrollee has pancreatic cancer. Single-agent Liposomal Irinotecan is not approvable. Therefore the requested service is not medically reasonable and 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 Onivyde have not been met. Therefore, we decided that the Plan does not have to pre-approve Irinotecan Liposome (Onivyde) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on May 23,
2019.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance service was medically
necessary. The Plan denied your request. The Plan says this transport was not a medical emergency and the
enrollee could have been transferred by ground ambulance.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services. Our reviewer
says that the service was not medically necessary. Our physician reviewer found the enrollee was transferred by
ambulance for initial stabilization. The enrollee was then transferred by air
ambulance to for more definitive therapy. The distance between the two
facilities is 14.6 miles. The documentation does support that the enrollee suffers from an illness or injury that
contraindicates transportation by any means other than ambulance.
The documentation does not support that the enrollee's condition was such that the time needed to transport a
patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or
seriously endangered the patient's health.
An ACLS ground ambulance would have been an appropriate means of transportation. The submitted records
do not indicate that such a ground ambulance was unavailable or that there were any unusual ground conditions
which required transport by air. The documentation does support that the transferring hospital did not have
adequate facilities to provide the medical services needed by the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the
Plan does not have to pay for services on May 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210) provided on
December 10, 2019 by an out of network provider.
You asked the Plan to reimburse you for the dental service. You say that you went to an in network dentist and
were told your blood pressure was too high so they couldn't perform the extraction. You say that you contacted
the plan for other in network providers and none were available until February 2020. You say that you were in
too much pain to wait and went to the out of network provider. The Plan denied your request. The Plan says the
provider in this case is not a participating general dentist. The Plan also says that in order for dental services to
be covered, they must be performed by a participating general dentist.
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 extractions are a covered service,
dental services must be performed by a participating general dentist in order to be covered. Therefore, we
decided that the Plan does not have to reimburse you for the surgical extraction (D7210) provided on December
10, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you did not receive services on this day. 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 $5 copayment per visit for an in-network PCP. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen on November 5, 2019 for a follow-up of diabetes and hypertension.
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 office visit provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for heart muscle imaging (78452) and a cardiovascular stress test
(93015) provided on September 27, 2019 through September 30, 2019.
You asked the Plan to pay for the heart muscle imaging and cardiovascular stress test. You say that you would
like reconsideration based on the records submitted. The Plan denied your request. The Plan says a secondary
only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
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 the heart muscle imaging and cardiovascular stress test are not supported in the record.
Specifically, this claim was submitted with I25.84 as the primary diagnosis. Per Medicare, I25.84 is a "code
first" code. This means that this diagnosis code cannot be listed as the primary or first listed on the claim.
Based on this information, we decided that Medicare rules for coverage of the heart muscle imaging and
cardiovascular stress test have not been met. Therefore, we decided that the Plan does not have to pay for heart
muscle imaging (78452) and a cardiovascular stress test (93015) provided on September 27, 2019 through
September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not
covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Synthroid for the enrollee.
Benefits for this drug 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and
pelvis without contrast rendered on October 13, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 74176 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 74176 and 74177. Code 74176 is a column II code with a
modifier indicator of 1 when billed with column I code 74177. Code 74176 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
computed tomography (CT) scan of the abdomen and pelvis without contrast rendered on October
13, 2019.