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

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says research has not found this to be helpful.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar spacer devices remain experimental in spinal surgery. More research is needed to show safety and efficacy 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement of aortic valve procedure (33405) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve a replacement of aortic valve procedure. You say that you were never told
that your visits to the cardiology provider at issue were not covered. The Plan denied your request. The Plan
says rules for out-of-network care have not been met.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a
replacement of aortic valve procedure (33405) to be provided by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthotic device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has deluxe features that exceed medical need, and replaces, rather than improves the function of the arm.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee had a right sided ischemic stroke in 2015 with resultant arm hemiparesis and spasticity. The medical records provided do not support the medical necessity and reasonableness, as defined by Section 1862 (a)1(A) and the 42 CFR 411.15(k) for the enrollee's specific clinical scenario. The elements of the coverage rule are not satisfied. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) and periodontal maintenance (D4910) provided on April 8, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test and periodontal maintenance. You say that you feel that these services should be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you are not enrolled in the dental supplemental benefit.
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 pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) and periodontal maintenance (D4910) provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-Ray examination provided on March 2, 2021.
You asked the Plan to waive the copayment for X-Ray. You say that you are not supposed to have copayment responsibilities to the Plan. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for in-network X-Ray. You have been asked to pay $20 copayment for X-Ray. X-Ray falls 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 copayment for an X-Ray examination provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
March 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on March
12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization (CPT code(s): 37243, 37242, 36245, 36246, 36247, 36248, 75625, 75710 ,75716, 75726, 76937, 99152, and 99153), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has a longstanding history of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms worsening over time. You state the enrollee is not a good candidate for medications or alpha blocker therapy as the enrollee was recently hospitalized for syncope. You state the enrollee has an IPSS score of 20 out if 35 consistent with severe symptoms and quality of life being 6 or terrible and they experience recurring nocturia and incomplete bladder emptying. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization (CPT code(s): 37243, 37242, 36245, 36246, 36247, 36248, 75625, 75710 ,75716, 75726, 76937, 99152, and 99153), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2750).
You asked the Plan to pre-approve the services. You say that you have a gap in your front teeth, and you want this gap covered. The Plan denied your request. The Plan says these services are not listed as a covered benefit.
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 dental services (D2750).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 17, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the six (6) office consultations (CPT code 99214) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve the office visits. You say that this is a cancer that is at risk of re-occurrence
and metastasis. You state that your doctor recommended that you wait no longer than six to eight weeks to
have this treated. You state the surgeon has told you that you will need to have a plastic surgeon reconstruct the
defect for the amount of tissue that will be removed to cut out all the cancer and this doctor is highly skilled at
the type of nasal reconstruction and has a very successful outcome for the best results. The Plan denied your
request. The Plan says there are network providers available.
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 provider at issue in this case is not a network provider with the Plan. 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 office visits. Our physician reviewer found as there are plastic surgeons that are capable of performing the reconstruction in-network, this care will be considered 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 office visits have not been met. 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 the office visits. Therefore, we decided that the Plan does not have to pre-approve the six (6) office consultations (CPT code 99214) to be provided by an out-of-network provide
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on February 18, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 physician/practitioner services/primary care visit. 

You have been asked to pay a $5 copayment for an office visit. An office visit falls within the physician/practitioner services/primary care visit 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 an office visit provided by a participating provider on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on September 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". 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 use of code 98110 is not supported by the records provided. Our coding reviewer found that the documentation
supports therapy was given in the home, therefore, CPT 97110 would be inappropriate code for this service. 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 for the services (97110) provided on September 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray provided on April 14, 2021.
You asked the Plan to waive the copayment for the hip x-ray. You say that this x-ray was a follow-up to a surgery so there shouldn't be a charge. The Plan denied your request. The Plan says this x-ray is not included in the surgery, so the provider is allowed to bill for the x-ray service.
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 Outpatient Diagnostic Tests.
You have been asked to pay a $42.28 copayment for the hip x-ray. The hip x-ray falls within the Outpatient Diagnostic Tests benefit category. Your copayment is less because the Medicare Allowable is less. 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. Radiological procedures are not included in the Global Surgery Package. Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on January 27, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Celecoxib cap.
You asked the Plan to pre-approve Celecoxib cap. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 Celecoxib cap.
Benefits for Celecoxib cap may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of abdomen and pelvis (74176) provided March 4, 2021.

You asked the Plan to waive the coinsurance for the CT scan of abdomen and pelvis. You say that you do not believe you should be charged for the care you received. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 $275 copayment for outpatient diagnostic radiology services. 

You have been asked to pay a total cost share of $238.41 for the CT scan of abdomen and pelvis which is less than the required $275 copayment. This service falls within the outpatient diagnostic radiology 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 coinsurance for the computed tomography (CT) scan of abdomen and pelvis (74176) provided March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two implant-supported porcelain/ceramic crowns (D6065 x2) provided on January 27, 2021.

You asked the Plan to pay for the implant supported crowns. You say that the glue came apart and you needed the implant crown secured. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Therefore, we decided that the Plan does not have to pay for the two implant-supported porcelain/ceramic crowns (D6065 x2) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for trigger point injections (20553) provided on February 11, 2021.
You asked the Plan to pay for trigger point injections. You say that this procedure is documented. The Plan denied your request. The Plan says this code 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 20553 is injection(s); single or multiple trigger point(s), 3 or more muscles. We find that CPT code 20553 is not supported in the medical record. Specifically, the submitted medical records only document injections in 2 muscles, both trapezius muscles. There is no documentation of an
injection into a third muscle. Based on this information, we decided that Medicare rules for coverage of trigger point injections have not been met. Therefore, we decided that the Plan does not have to pay for trigger point injections (20553) provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urinary collection device (K1006).
You asked the Plan to pre-approve the urinary collection device. You say that the device is medically necessary. The Plan denied your request. The Plan says this is not a covered item and there is no documentation of a urology consult.
The Plan must follow Medicare rules. Medicare rules say that for female external urinary collection devices, more than one meatal cup (A4327) per week, or more than one pouch (A4328) per day will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The requested device is not a meatal cup or pouch device. Based on this information, we decided that Medicare rules for coverage of the urinary collection device have not been met. Therefore, we decided that the Plan does not have to pre-approve a urinary collection device (K1006).