Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services providedfrom August 11, 2020, through August 24, 2020.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the available medical information does not support the need for an authorization to a non-plan provider, such as a lack of this specialty provider in thePlan's network or an urgent/emergent situation that requires the services of a non-plan provider.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 did not pre-approve the psychotherapy services. 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 psychotherapy services providedfrom August 11, 2020, through August 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on July 30, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on July 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room ( (ER) visit on August 
21, 2020. 
 
You asked the Plan to waive the copayment for the emergency room ( (ER) visit. You said that you were told 
that you would not be billed for the emergency room visit. The Plan denied your request. The Plan says the 
copayment in the amount of $90.00 is your financial responsibility. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This service falls within the 
Emergency Care Benefits Plan 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 emergency room ( (ER) visit on August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCT scan of the abdomen and pelvis.You asked the Planto pre-approvethe scan. You say that delaying this will make it worse.The Plandenied your request. The Plansaysthere is information concerning a prior plain x-ray or ultrasound imaging.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a review of the records revealed no focal abdominal pain or tenderness during exam of 11/18/20. You were afebrile at the time. There are no details concerning a prior history of colitis in the past. There are no lab results showing elevated white count or other findings to indicate active colitis.  There is no history of bloody stools. Interestingly, there is no mention of GI workup including colonoscopy. Absent these clinical items of information the medical necessity of CT of the abdomen and pelvis has not yet been established.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCT scan of the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forgingival irrigation upper left, upper right, lower left (D4921), localized delivery antimicrobial teeth #14, #13, #20 (D4381) and topical application of fluoride (D1206) provided on September 24, 2020, through September 29, 2020.You asked the Plan to pay forgingival irrigation, localized delivery antimicrobial and topical application of fluoride. You say that the services should be covered.The Plan denied your request. The Plan says the services are not covered under your benefit plan.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. Specifically, the services were not listed in the Plan's 2020 benefit chart making them non-covered services.Therefore, we decided that the Plan does not have to pay forgingival irrigation upper left, upper right, lower left (D4921), localized delivery antimicrobial teeth #14, #13, #20 (D4381) and topical application of fluoride (D1206) provided on September 24, 2020, through September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Icosapent Ethyl. 
 
You asked the Plan to pre-approve Icosapent Ethyl. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 Icosapent Ethyl.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 25, 
2020. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the train of four monitoring 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. The 
rules also say that all services integral to accomplishing a procedure are considered bundled into that procedure 
and, therefore, are considered a component part of the comprehensive code.  
 
We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is integral to 
the primary procedure. Separate payment may not be made for this service. Based on this information, we 
decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we 
decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq tablet, 50 mg. 
 
You asked the Plan to pre-approve Myrbetriq tablet. You say that the enrollee has been treated with other 
therapies with unsuccessful results. You say that the enrollee has been on Myrbetriq since August 2016. You 
also say that the enrollee's symptoms have improved and is very happy with the results. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Myrbetriq tablet, 50 mg.  
 
Benefits for Myrbetriq tablet 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 additional transportation miles (A0710). 
 
You asked the Plan to pre-approve additional transportation miles. You say that the service is necessary. The 
Plan denied your request. The Plan says the service exceeds the benefit maximum allowed. 
 
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 50 miles 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. Specifically, your 
plan allows 50 miles for each one-way routine transportation trip. You requested 53 miles which is over the 
maximum mileage allowed. Therefore, we decided that the Plan does not have to pre-approve additional 
transportation miles (A0710).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ceftriaxone. 
 
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 that eight units daily for 28 days is not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee is diagnosed with Lyme 
disease with symptoms present for over three years. Recent symptoms of headache, neck pain, and fatigue were 
reported recently similar to before. Six bands on the IgG Western Blot were positive. Late Lyme disease was 
suspected. Two grams of Ceftriaxone intravenously were prescribed and requested for a 28-day course due to 
failing oral doxycycline. The documentation provided does support the medical necessity of IV ceftriaxone for 
this challenging case of late stage Lyme disease failing oral doxycycline. The ceftriaxone is safe and effective 
and medically necessary at this time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Ceftriaxone.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of bone (D7473) and deep sedation/general 
anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve removal of bone and deep sedation. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not covered under your benefit plan. 
 
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. Specifically, the services requested are not listed in the Plan?s benefit 
chart. This means the services are not covered under your benefit plan. Therefore, we decided that the Plan 
does not have to pre-approve removal of bone (D7473) and deep sedation/general anesthesia (D9222 and 
D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on October 1, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was your annual visit with 
your primary care doctor and you should not have a copayment. 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 for primary care physician office visit/other health care professionals.  
 
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 for an annual exam and for diabetes mellitus. 
 
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 October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a small bathtub. 
 
You asked the Plan to pre-approve these services. You say that you have falls when you try to get in and out of 
the tub. The Plan denied your request. The Plan says the services are not covered. 
 
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 Plan does not have to pre-approve a small bathtub.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Infliximab injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria has not been met.

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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly show a recent (past year) negative TB test. Because of this, the safety of the drug for the enrollee is not sufficiently clear enough to justify administration of infliximab at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Infliximab injection for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transport lodging receipt (A0180), non-
covered item or service (A9270), and transplant related lodging, meals and transportation, per diem (S9975) 
provided on August 3, 2020, through August 28, 2020. 
 
You asked the Plan to pay for non-emergent transport lodging receipt, non-covered item or service, and 
transplant related lodging, meals and transportation.. You say that the services should be covered. The Plan 
denied your request. The Plan says the services are not covered under your benefit plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the location must be a minimum of 75 miles 
outside your home for transportation and lodging costs to be reimbursed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergent transport lodging receipt, non-covered item or service, and transplant related 
lodging, meals and transportation have not been met. Specifically, your home is less than the required 75 mile 
minimum distance from the facility. This means the services are not covered. Therefore, we decided that the 
Plan does not have to pay for non-emergent transport lodging receipt (A0180), non-covered item or service 
(A9270), and transplant related lodging, meals and transportation, per diem (S9975) provided on August 3, 
2020, through August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace provided on December 13, 
2018. 
 
You asked the Plan to waive the coinsurance for the knee brace. You submitted your bill for review. 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 20% 
coinsurance for each Medicare-covered item.  
 
You have been asked to pay $167.06 which is 20% of the allowed amount for the knee brace. The allowed 
amount is $835.28. ($835.28 x 20% = $167.06). The knee brace falls within the "Durable medical equipment 
(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 the knee 
brace provided on December 13, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313) and a power 
seat elevation system (E2300). 
 
You asked the Plan to pre-approve an expandable controller  and a power seat elevation system. You say that 
the enrollee needs these items. The Plan denied your request. The Plan says these items are not covered in this 
case. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller is covered when needed 
to accommodate one or more of the above functions. A power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The record shows that an expandable controller is not needed to 
accommodate one or more of the above functions. No other proportional or non-proportional input devices, 
displays, attendant controls, or other devices have been requested and approved, and only two power options 
have been approved. The power seat elevation system is a non-covered item. Based on this information, we 
decided that Medicare rules for coverage of an expandable controller  and a power seat elevation system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377, E2313) and a power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 24, 
2020, through September 25, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services could have been received at an observational 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 record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient'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. Specifically, the services 
received could have been at an observational level of care. This means the services were not reasonable or 
necessary. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care 
provided September 24, 2020, through September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical information does not support the medical necessity of this service. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has a diagnosis of COPD, but there is no documentation of CO2 retention on arterial blood gas testing while in 
a stable state. There is no evidence that BiPAP has been tried, and that it has failed by Medicare criteria. 
Medicare does not cover a home ventilator when used as BiPAP.  A home ventilator is not 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.