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

We decided that the Plan does not have to pre-approve the implantation of a peripheral nerve neurostimulator (64555, 76942).

You asked the Plan to pre-approve the implantation of a peripheral nerve neurostimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices 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 implantation of a peripheral nerve neurostimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational approach for the enrollee's condition.

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 implantation of a peripheral nerve neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a peripheral nerve neurostimulator (64555, 76942).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of congestive heart failure, as well as coronary artery disease, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. Therefore, the enrollee does not meet criteria for the requested 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. 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 Modafinil tablets.
Benefits for self-administered 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services for the enrollee.
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 inpatient hospital services. Our reviewer says that that inpatient hospital services are not medically reasonable and necessary for the enrollee. The planned procedure listed under CPT codes 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The enrollee is medically stable. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like additional routine transportation trips covered. The Plan denied your request. The Plan says the benefit for routine transportation is exhausted.
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 40 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you 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 trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953), a customer abutment (D6057), an implant placement (D6010), and an implant supported crown (D6066).
You asked the Plan to pre-approve the dental services. You say that you are dissatisfied with the services and benefits. You also say that you would like to terminate coverage with your dental plan. The Plan denied your request. The Plan says a partial denture would adequately replace tooth. The Plan says that we must approve the most cost-effective treatment for replacing your missing teeth. The Plan also says that a partial denture is the more cost-effective treatment to replace more than one missing tooth in the same part of your mouth. The Plan also says that the requested dental services are not medically necessary.
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 services 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 services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation provided did not indicate that a removable partial was contraindicated due to medical or psychological issues. Therefore, the reviewer found that the requested dental services are not medically reasonable or necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953), a customer abutment (D6057), an implant placement (D6010), and an implant supported crown (D6066).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection.

You asked the Plan to waive the copayment for the lumbar injection. You say that the copayment for each date is too high. The Plan denied your request. The Plan says the copayments applied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a total of $590 for the lumbar injections.

The lumbar injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 the lumbar injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services.

You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file, and Medicare rules. The record shows the enrollee, complaining of leg pain was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Emergency treatment was not needed for transport. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence of an established relationship between the member and ordering physician. Of note, the ordering physician is located in one state while the member and laboratory are located in another. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee walked 200 feet and then 100 feet. The enrollee required contact guard assistance to stand up. The enrollee negotiated three stairs times two. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a qualified professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. As a practical matter, the enrollee's care needs can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Chronic diastolic (congestive) heart failure, as well as atrial fibrillation and chronic obstructive pulmonary disease (COPD), diabetes and hypertension. The enrollee was recently hospitalized, reportedly with congestive heart failure and atrial fibrillation. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. Therefore, the enrollee does not meet criteria for the requested 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a repeat sleep test.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says that Medicare can only pay for services that are medically necessary and reasonable.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found a repeat attended study is considered reasonable and necessary. You were diagnosed with OSA in 2017,
with an apnea-hypopnea index (AHI) of 12, although much higher during rapid eye movement (REM) sleep.
You tried continuous positive airway pressure (CPAP) briefly, but you did not tolerate it. You are having
increasing memory problems and nocturia and want to try CPAP again. A home sleep test did not confirm
OSA. However, the home sleep test is known to be less sensitive for OSA than formal attended
polysomnography (PSG). The original diagnosis of OSA established in 2017 is likely to be correct but needs to
be confirmed with a repeat attended PSG before again trying CPAP.
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 testing have been met. Therefore, we decided that the Plan has to preapprove
a repeat sleep test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement services (11721) provided on October 12, 2020.
You asked the Plan to waive the copayment for the nail debridement. You say that this was a routine visit and your health plan usually pays their fair share. The Plan denied your request. The Plan says this was not a routine visit, and the allowed amount for the service was less than your copayment 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 podiatry services. You have been asked to pay a $40.91 copayment for nail debridement. According to the medical records, this visit was a follow up for a previous issue. A routine visit is care that is provided when there is no evident problem. An annual wellness visit is an example of routine care; a follow-up is not routine. Podiatry services that are covered with a $50 copayment include diagnosis and the medical or surgical treatment of injuries and diseases of the feet. The Plan's allowed amount for this service is $40.91. Because the amount that is allowed by the Plan is less than the required copayment, you only pay the allowed amount.
Nail debridement falls within the podiatry 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 nail debridement services (11721) provided on October 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

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 admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with altered mental status, agitation, and aggression. The physical therapy note states she is modified independent with rolling, sitting up, scooting, and lying down. She needs stand-by assist with walking 300 feet with a walker. She has no skilled nursing needs. She has no skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.

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 a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion.

You asked the Plan to waive the copayment for the intravenous infusion. You say that you needed IV therapy
because of your osteoporosis. You say that you do not agree with the bill. The Plan denied your request. The
Plan says the copayment applied 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 $395
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $215.36, which is less than the standard $395 copayment for the intravenous
infusion. The intravenous infusion falls within the "Outpatient Surgery and Other Medical Services Provided at
Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 the intravenous infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 15, 2020 by a non-participating 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 a non-participating 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 Plan had network providers available who could have provided 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 physician services provided on July 15, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81407, 81479).

You asked the Plan to pay for cardiomyopathy risk factor screening. You say that this was medically necessary.
The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular
(CV) risk assessment panels, except the basic lipid panel, 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.

Based on this information, we decided that Medicare rules for coverage of cardiomyopathy risk factor
screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy risk
factor screening (81407, 81479).