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

We decided that the Plan has to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer J1439. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says that the notes do not show the enrollee has tried iron by mouth.
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 Injectafer J1439. Our reviewer says that the drug is medically necessary. Our physician reviewer found intravenous iron is indicated in patients with significant anemia unlikely to absorb iron without a trial of oral iron. Elderly patients have poor oral iron absorption and this enrollee is also on omeprazole which inhibits absorption. The use of intravenous iron is reasonable and 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 Injectafer J1439 have been met. Therefore, we decided that the Plan has to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies from June 12,
2020 to September 12, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you are on disability
and cannot afford 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 DME and related supplies.
You received DME and related supplies from June 12, 2020, to September 12, 2020, for a total of 4. The total
allowed amount per each date of service is $158.03 and 20% of that is $31.60. The total amount you owe is:
$31.60 (coinsurance) x 4 (dates of service) = $126.42.
You have been asked to pay the total coinsurance amount of $126.42 for DME and related supplies. DME and
related supplies fall within the DME and related supplies 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 DME and related supplies from June 12, 2020 to September 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient hospital services provided to the enrollee from April 13, 2020 to April 14, 2020.You asked the Planto pay foracute inpatient hospital care. You say that this should be paid for.The Plandenied your request. The Plansaysthis does meet the criteria for observation level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient hospital services provided to the enrollee from April 13, 2020 to April 14, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvehip arthroscopy (29860).You asked the Plan to pre-approvehip arthroscopy (29860). You say that the requested hip arthroscopy (29860) is medically necessary.The Plan denied your request. The Plan says that the requested hip arthroscopy (29860) is not medically necessary.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 hip arthroscopy (29860). Our reviewer says that the requested hip arthroscopy (29860) is medically necessary. Our physician reviewer found this enrollee presents status post left hip arthroscopic labral repair, acetabuloplasty with subspine decompression, chondroplasty of the acetabulum, femoroplasty,gluteus medius repair, and trochanteric bursectomy on 9/23/20. She reported a recurrence of significant left hip pain 6 weeks' post-operative following discontinuation of bracing and crutches. Clinical exam findings are consistent with recent left knee MRarthrogram that confirmed capsular defect, as well as a possible tear of gluteus medius tendon and suspected seroma at the site of trochanteric bursectomy. She has failed over 2 months of reasonable and comprehensive conservative treatment, including activity modification, limited weight bearing, continuous passive motion, bracing, physical therapy, and home exercise program. Under consideration is a request for left hip arthroscopy, capsular repair with Bioinductive implant, and possible revision gluteus repair (CPT code 29860). Current evidence based medical literature would support revision surgery to relieve pain and improve function. Therefore, this request for hip arthroscopy (CPT code 29860) is 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 hip arthroscopy (29860) have been met.Therefore, we decided that the Plan has to pre-approvehip arthroscopy (29860).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foradvance care planning services (CPT 99497) provided to the enrollee on September 8, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99497 25 (1 unit) remains 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 99497 is "Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate."We asked our coding 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 services. Our reviewer says that the servicesat issue in this case were not supported by the medical records. Our coding reviewer found the medical records provide do not include sufficient information to validate that Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate was performed on September 8, 2019, therefore this service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay foradvance care planning services (CPT 99497) provided to the enrollee on September 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four extractions provided by an OON 
provider. 
 
You asked the Plan to pay for the extractions. You say that the enrollee was not able to find an authorized 
dentist, and had no choice but to go to an OON provider. The Plan denied your request. The Plan says these 
services were rendered by a provider who is not in the Plan's network. The Plan also says that the enrollee must 
use network providers to receive dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the four 
extractions provided by an OON provider.  
 
Your complaint about your disagreement with the Plans decision 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you lose your balance from medications. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on February 11, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that this provider has been your dentist for many years, 
and your dental services rendered by him in 2019 were paid by the Plan. You also say that this treating 
provider's Medicare enrollment status has not changed. The Plan denied your request. The Plan says the 
treating provider has opted out of Medicare. The Plan also says that charges incurred by Medicare opt out 
providers will not be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis provided on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on July 22, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you cannot afford 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 $110
copayment per each radiological diagnostic service.
You received two ultrasounds on July 22, 2020. Therefore, you are responsible to pay the total allowed amount
of $110.68, which is less than the total copayment amount.
You have been asked to pay the total copayment amount of $110.68 for ultrasounds. Ultrasounds fall within the
outpatient diagnostic tests and therapeutic services and supplies 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 copayments for ultrasounds provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) provided on July 28, 2020. 
 
You asked the Plan to pay for the core build up. You say that the root canal and post were necessary to retain 
your bridge. You say that these services are necessary to extend the life of your bridge. The Plan denied your 
request. The Plan says core build up is listed as a covered service. The Plan also says that it is not covered if the 
procedure is not performed together with a crown. 
 
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, core build up is not covered unless it is 
performed in conjunction with a crown. The record shows that the provider's office confirmed  that no new 
bridge or crown was being done at the same time of the core build up. Therefore, we decided that the Plan does 
not have to pay for the core build up (D2950) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased July 1, 2020, from an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the frames and lenses. You say that you would like this claim processed and 
approved for payment based on your yearly frame reimbursement rate. The Plan denied your request. The Plan 
says reimbursement is not available since services were provided by an entity other than the Plan's routine 
vision care provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when purchased from the Plan's routine vision care provider. 
 
We looked at the file and the Plan's rules. The information indicates that the frames and lenses were purchased 
from an OON provider and not from the Plan's routine vision care provider. Based on this information, we 
decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for the frames and lenses purchased July 1, 2020, from an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProton beam therapy for the enrollee.You asked the Plan to pre-approveProton beam therapy. You say that this treatment is medically necessary.The Plan denied your request. The Plan says medical necessity has not been established.The Plan must follow Medicare rules. Medicare rules say that itemsand 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 Proton beam therapy. Our reviewer says that medical necessity has not been established. Our physician reviewer found a3D plan would not necessarily facilitate lowering the marrow dose as AP and lateral beams can be used with 2D fields to minimize dose to other bones. Our reviewer says that the need for 3D radiation has not been substantiated 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 Proton beam therapy havenot been met.Therefore, we decided that the Plan does not have to pre-approveProton beam therapy for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an abdominal ultrasound.

You asked the Plan to pre-approve an abdominal ultrasound. You say that the requested abdominal ultrasound is medically necessary.The Plan denied your request. The Plan says that the requested abdominal ultrasound is not medically necessary.

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 an abdominal ultrasound. Our reviewer says that the requested abdominal ultrasound is medically necessary. Our physician reviewer found the enrollee is diagnosed with immune thrombocytopenic purpura (ITP). ITP requires no splenomegally, thus spleen ultrasound is indicated 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 an abdominal ultrasound have been met.Therefore, we decided that the Plan has to pre-approvean abdominal ultrasound.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services provided on May 7, 2020 billed with codes 19370-50-51, 19370-59-50-51, 15771, and 15772.You asked the Plan to pay forthe services as billed. You say that these codes are supported,and the claim should be paid as billed.The Plandenied your request. The Plan says the only code that is supported was 19830-50; the other billed codes are not supported by the operative report.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 asked our coding 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 services as billed.Our reviewer says that the documentation does not support the billing of these codes. Our coding reviewer found code 19370 is defined as Open periprosthetic capsulotomy, breast. The operative report did not include documentation that scar tissue formed around breast implants were removed. Therefore, this code cannot be verified.  There is a more specific code that appliers for capsulorrhaphy. In the case for 15771, defined as Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate, and 15772, which is used for each additional 50 cc injectate, the operative report did not include documentation to support a distinct procedural service was performed. As such, the separate billing of these codes is not supported.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services provided on May 7, 2020 billed with codes 19370-50-51, 19370-59-50-51, 15771, and 15772.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from January 13, 2020, to January 14, 2020.
You asked the Plan to pay for the medical services. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the medical services provided from January 13, 2020, to January 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits.You asked the Plan to pre-approvehome health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits. You say that the requested home health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for home health care.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits. Our reviewer says that the enrollee does not meet criteria for home health care. Our physician reviewer found in order to require Home health care skilled services, the member must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician.  Additionally, the member must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy.  Being homebound means leaving home is a major effort.  In this case, the documentation doesn't support that the member is home bound.  He appears to be participating in outpatient Physical Therapy. The member does not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problemsor hospitalizations.  He is not home bound and he does not have any skilled needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health care to include speech therapy, blood draws, blood pressure monitoring and psychotherapy visits