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

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Superion IDS).You asked the Plan to pre-approve Superion IDS. You say that the enrollee meets commonly accepted medical criteria for surgical intervention, and will benefit more from Superion IDS as opposed to  more invasive procedure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is 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 Superion IDS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. There has been no head-to-head trial versus lumbar decompression which is the standard 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 Superion IDS have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous stabilization device (Superion IDS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on January 21, 2020. You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You say that you have been informed that the dentist was supposed to call the Plan for authorization for these services which he did not do. You also say that you did not know in advance what treatment would be needed so you could have called yourself. The Plan denied your request. The Plan says these services are not covered under your 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 first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 26, 2019 to December 27, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the inpatient services were medically necessary.The Plan denied your request. The Plan says there was no authorization for the inpatient 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 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 showed that at the time of inpatient admission the admitting physician did not reasonably expect 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.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 26, 2019 to December 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) provided November 21, 2019.
You asked the Plan to pay for the dental services. You say that this was a normal dental cleaning and you was never told any of this when you called to check status on this before. This was approved earlier in year, why would it be denied now? The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for periodontal scaling and root planning (D4341) provided October 29, 2019 to November 5, 2019.
You asked the Plan to waive the copayment for the dental services. You say that the plan should have paid $300 for both dates since according to the 2019 enrollment guide the deductible does not apply and you have been assured that you only pay 50% for out of network dentists The Plan denied your request. The Plan says the deductible and cost share was applied correctly per the plan benefits.
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 50% for in network and out of network providers. You may be billed by the out-of-network provider for any amount greater than the payment made by the plan to the provider or any services not covered by the plan. There is a $100 deductible. The deductible doesn't apply to exams, bitewings, all x-ray services, cleanings, or fluoride. You have been asked to pay $1024 for the dental services. The dental services fall within the Platinum Dental Rider 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 periodontal scaling and root planning (D4341) provided October 29, 2019 to November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an extremity brace (L3809) provided December 14, 2019.
You asked the Plan to waive the coinsurance for the brace. You say that you didn't need the brace so the coinsurance should be waived. The Plan denied your request. The Plan says the correct coinsurance was charged.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Prosthetics and Braces. You have been asked to pay a 20% coinsurance for the brace. The brace falls within the Prosthetics and Braces 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 an extremity brace (L3809) provided December 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on June 19, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, nonurgent
services with out-of-network providers require 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 did not pre-approve the
drug test. 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 a drug test provided on June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 6, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 service 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 a hospital outpatient clinic visit provided on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided October 27 to November 5, 2019.You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not medically necessary and were provided out-of-network.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our reviewer says that inpatient level services were not medically necessary. Our physician reviewer found the enrollee does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to herself or others, and was noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided October 27 to November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator and portable gas oxygen system provided on January 15, 2020.
You asked the Plan to pay for the oxygen concentrator and portable gas oxygen system. You say that you thought your equipment was approved. The Plan denied your request. The Plan says there was no authorization approved prior to services rendered.
Medicare rules say that Plans may require enrollees to obtain authorization before receiving services. 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 oxygen concentrator and portable gas oxygen system provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrelegy Ellipta.You asked the Plan to pre-approve the Trelegy Ellipta. You say that this is necessary.The Plan denied your request. The Plan says this self-administered drug cannot be covered by 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 Trelegy Ellipta.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 14, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing and/or skilled rehabilitation services on a daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 14, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on May 30, 2019.
You asked the Plan to pay for the subsequent hospital care. 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 subsequent hospital care provided on May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on November 18, 2019.You asked the Plan to waive the copayment for lab work. You say that you had the same test done before and you were not charged this much.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 $35 copayment for outpatient diagnostic tests/in-network/labs. You have been asked to pay $29.55 which is less than your copayment amount of $35 for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/in-network/labs 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 lab work provided by a participating provider on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible, coinsurance, and copayment for lab work, an injection and an office visit provided by a participating provider on October 30, 2019.You asked the Plan to waive the deductible and copayment for lab work and an office visit, and coinsurance for an injection. You say that you do not agree with any of these charges.The Plan denied your request. The Plan says the correct cost-sharing amounts have 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 10% coinsurancefor Medicare Part B prescription drugs/in-network/provider's office, a $20 copayment for outpatient diagnostic tests/in-network/labs and $35 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a 10% coinsurance of the allowed amount for an injection. The total allowed amount is $1.57. The total amount you are being asked to pay for an injection is $.16 ($1.57 x 10% = $.16).The total deductible amount you have been asked to pay is $48.22 for lab work. You have been asked to pay a$20 copaymentfor lab work and $35 copayment for an office visit.The total amount you are being asked to pay is $103.38 ($.16 + $35 + $20 + $48.22 = $103.38). Lab workfalls within the outpatient diagnostic tests/in-network/labs benefit category, an injection falls within Medicare Part B prescription drugs/in-network/provider's office benefit category an office visit falls within the physician/practitioner services/in-network/specialist 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 deductible and copayment for lab work and an office visit, and coinsurance for an injection provided by a participating provider on October30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (J9022).You asked the Plan to pre-approve Tecentriq. You say that the requested medication is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 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 Tecentriq. Our reviewer says that the medication is necessary. Our physician reviewer found in this case, the enrollee does not meet criteria for the requested treatment due to definite disease progression noted on the positron emission tomography (PET) scan following therapy with PD-L1 therapy (Keytruda). The review has determined that the documentation does not support that the Tecentriq is medically reasonable and necessary for the enrollee. The documentation does not support that the Tecentriq is safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met.Therefore, we decided that the Plan does not have to pre-approve Tecentriq (J9022).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Clarifix procedure.
You asked the Plan to pre-approve the Clarifix procedure. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says Clarifix is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Clarifix procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Clarifix should only be used in patients who have benefited from an anticholinergic nasal spray. The record does not indicate whether the member had benefit from the ipratropium nasal spray. 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 Clarifix procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Clarifix procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an operative MRI for PSI (73721).
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because you have knee pain and have had x-rays and cortisone shots. The Plan denied your request. The Plan says it is not reasonable and necessary to utilize MRI prior to total knee arthroplasty.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the medical necessity of a pre-operative MRI for the requested total knee arthroplasty is not supported by evidence based medical guidelines or peer-reviewed literature. Our physician reviewer found there are no large volume, high quality clinical trials that confirm the clinical benefits (ultimate outcomes of functionally improvement and pain reduction) of patient specific instrumentation for total knee arthroplasty. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an operative MRI for PSI (73721).