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

We decided that the Plandoes not haveto pre-approve3D imaging for a CT scan for the enrollee.You asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysthe 3D imaging is considered part of the test, and not covered separately.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 imaging. Our reviewer says that the requested imaging not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been approved for CT of the hip/pelvis which includes sagittal and coronal reformatting as part of the exam, CPT 72192. The necessity of separate 3D reformatting at a separate workstation -CPT 76376 has not been established in the records submitted.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of the imaging have not been met.Therefore, we decided that the Plandoes not haveto pre-approve3D imaging for a CT scan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone, 10 mg tablet.You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says Prednisone is a drug that you give to yourself. The Plan says you have a medical only policy, not a Prescription Drug Plan. The Plan also says that Medicare Part B does not cover drugs that are usually self-administered.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 Prednisone, 10 mg tablet.Benefits for Prednisone 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 30 and 31.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says according to the information reviewed on appeal, there is no evidence of a need for replacement of the existing 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. The Plan coverages dental crowns when 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 these services. Our reviewer says that you do not meet criteria for coverage of the requested dental crowns. Our physician reviewer found that the crowns already in place appear to be in good function with no observable defects or tooth decay. 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 30 and 31.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 27, 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 12002 is not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 12002 is simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm. We find that CPT code 12002 is not supported in the medical record. Specifically, the records do not indicate that simple repair of a wound of 2.6 cm to 7.5 cm was performed. 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 pay for the surgical services rendered on May 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan IV infusion. You asked the Plan to pre-approve Rituxan (J9312). You say that you want the enrollee to be treated with Rituxan. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Remicade or Inflectra and Simponi Aria. 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 Rituxan (J9312). Our reviewer says that Rituxan is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of inflammatory polyarthropathy involving multiple joints. The enrollee has not tried and failed the required drugs. The documentation does not support that Remicade or Inflectra and Simponi Aria would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan (J9312) have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan IV infusion.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on November 26, 2019.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges. 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 $10 copayment for outpatient rehabilitation services provided in a specialist's office and a $40 copayment when provided in an outpatient hospital facility. The record shows that you received outpatient rehabilitation services in an outpatient hospital facility on November 26, 2019. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation to be provided by provider.You asked the Plan to pre-approve routine transportation. You say that you are being treated but do not have money from transportation.The Plan denied your request. The Plan says the denial of authorization for additional routine transportation trips is correct, because routine transportation beyond 24 one-way trips per calendar year is not covered by the Plan.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 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 you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation to be provided by provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic tablets.
You asked the Plan to pre-approve Bystolic tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Bystolic tablets are not covered under the enrollee's Medicare Part B benefit.
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 Bystolic tablets.
Benefits for Bystolic tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on May 20, 2019.
You asked the Plan to waive the coinsurance for the injection. The Plan denied your request. The Plan says that this paid 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 the Prolia injection provided on May 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea recliner chair.You asked the Planto pre-approvethe chair. You say that this is medically necessary.The Plandenied your request. The Plansaysitems that are primarily for the comfort and convenience of enrollees are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring supplies (HCPCS A4556) provided to the
enrollee on May 30, 2019.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request.
The Plan says this service is considered a bundled procedure, as the cost is included in the cost of the primary
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, the CPT Code Manual definition of HCPCS code A4556 is "electrode."
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 supplies. Our reviewer says that the
supplies at issue in this case were not coded correctly. Our physician reviewer found the medical records
submitted indicate that spinal surgery was performed and neurophysiology monitoring was utilized. HCPCS
A4556 is a bundled service that is included in the payment for the primary service that was performed and paid
by the health plan.
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 supplies have not been met. Therefore, we decided that the Plan does not
have to pay for monitoring supplies (HCPCS A4556) provided to the enrollee on May 30, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 19, 2019 through November 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights . 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 19, 2019 through November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from December 14, 2018 to September 20, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on December 14, 2018. The allowed amount is $31.40 and 20% of that is $6.28. You received a Medicare Part B drug on September 20, 2019. The allowed amount is $7.70 and 20% of that is $1.54. The total amount you owe is: $7.82. You have been asked to pay the total coinsurance amount of $7.82 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided from December 14, 2018 to September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 30, 2019.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 Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance was called because you were dazed, unable to sit up with no control of your arms, and speaking incoherently. You are diabetic and your wife tested your blood sugar and found that it was very low. You say that there was nothing she could do to help you so she called for emergency assistance. The responders tested and immediately treated you bringing your blood sugar back up. Within a short amount of time you became coherent and began to feel okay. You did not think it was necessary to go to the ER and incur an ER visit charge just to be evaluated and released. You stated that you knew it was just a low blood sugar incident and have encountered the situation before. You say that you did not know you would be charged for this service and that it is a financial hardship for you. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 25, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hand surgery for release/relocation of the median hand nerve (carpal tunnel surgery).
You asked the Plan to pre-approve carpal tunnel surgery. You say that the enrollee had a failed course of splinting. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documentation that conservative measures have been tried and failed for the appropriate length of time.
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 carpal tunnel surgery. 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 wrist splinting or any other conservative measure for treatment. There are no red flags for surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hand surgery for release/relocation of the median hand nerve (carpal tunnel surgery).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Intraspinous Spacer (22869, 22870). You asked the Plan to pre-approve the insertion of a Vertiflex Intraspinous Spacer. You say that this procedure is considered reasonable and medically necessary by Medicare contractors. The Plan denied your request. The Plan says this is experimental. 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 insertion of a Vertiflex Intraspinous Spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show efficacy and safety of the device. 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 insertion of a Vertiflex Intraspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Intraspinous Spacer (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial dentures (D5225) and lower partial dentures (D5226).
You asked the Plan to pre-approve upper and lower partial dentures. You say that the requested items are necessary. The Plan denied your request. The Plan says the items 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 upper partial dentures (D5225) and lower partial dentures (D5226).