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

We decided that the Plan does not have to waive the copayment for an MRI scan of the lumbar spine (72158) provided on January 21, 2021.
You asked the Plan to waive the copayment for a spinal MRI. You say that you were not informed in advance about this charge. The Plan denied your request. The Plan says the correct copayment was 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 $225 copayment for per day per provider for Medicare-covered diagnostic radiology services. You have been asked to pay a $225 copayment for a spinal MRI. A spinal MRI 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 MRI scan of the lumbar spine (72158) provided on January 21, 2021.
Your complaint about not receiving adequate information about your cost-sharing responsibilities from your provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture (D5213), mandibular partial denture (D5214), extraction of erupted tooth (D7140), and surgical removal of erupted tooth (D7210).
You asked the Plan to pre-approve maxillary partial denture, mandibular partial denture, extraction of erupted tooth, and surgical removal of erupted tooth. You say that these services are medically necessary because you are in pain. The Plan denied your request. The Plan says these are not covered services under your 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 pre-approve maxillary partial denture (D5213), mandibular partial denture (D5214), extraction of erupted tooth (D7140), and surgical removal of erupted tooth (D7210).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cataract surgeries (66984) performed on
September 25 and October 9, 2019.
You asked the Plan to waive the coinsurance for cataract surgeries. You say that you have Medicare that covers
80% and the Plan that covers 20%. The Plan denied your request. The Plan says the correct coinsurance was
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 20%
coinsurance for each covered surgery in an ambulatory surgical center.
You have been asked to pay $223.57 per date of service, or 20% of the Medicare-allowed amount of $1,117.87,
for cataract surgeries. Cataract surgeries fall within the "Outpatient surgery, including 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 coinsurance for cataract surgeries (66984) performed on September 25 and October 9, 2019.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities
from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 27,
2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan
says that the correct copayment has applied per your contract with the Plan. 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 $105
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility (such as a radiology center or medical clinic).
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound on
August 27, 2020. You have been asked to pay an $80.11 copayment for the ultrasound, which is less than the
contracted $105 copayment amount. The ultrasound falls within the Outpatient diagnostic tests 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 ultrasound provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851). You asked the Plan to pre-approve a knee orthosis. You say that this device is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the records do not demonstrate recent injury
or surgery or that instability of enrollee's knee.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis is subject to the criteria listed in the
Medicare rules section.
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 a knee orthosis. Our reviewer says that
the requested knee orthosis is not medically necessary and reasonable. Our physician reviewer found the
patient is ambulatory. There is no evidence in the documentation of a recent injury, surgery, or an objective
evaluation indicating instability on a knee exam. Therefore, the coverage criteria for the knee orthosis have not
been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1851).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided on October 1, 2020.
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received an outpatient surgical procedure in an outpatient hospital facility setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for Outpatient surgery provided in an outpatient hospital facility setting. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received an outpatient surgical procedure in an outpatient hospital facility setting. The file shows that the enrollee's provider is located within an outpatient hospital facility setting. The enrollee has been asked to pay an $80.70 copayment for the outpatient surgical procedure, which is less than the contracted $300 copayment amount. The outpatient surgical procedure falls within the Outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided on October 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the enrollee has previously been treated with Hyalgan. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Synvisc. Our reviewer says that the criteria for coverage of Synvisc have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The case file does not contain documentation of trial and failure of Orthovisc and Monovisc. It also does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments from $345 to $245 for the cataract surgeries (66984) provided on November 4, 2020 and December 2, 2020.
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $345 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 $690 ($345 copayment x 2) for the outpatient surgeries provided. 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 adjust the copayments from $345 to $245 for the cataract surgeries (66984) provided on November 4, 2020 and December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant at surgery services for current procedural terminology (CPT) code 27603 provided on October 8, 2020.
You asked the Plan to pay for CPT code 27603. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 27603. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant at surgery services for CPT code 27603 have not been met. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services for current procedural terminology (CPT) code 27603 provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on June 15, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for the durable medical equipment provided on June 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on July 10, 2020.
You asked the Plan to waive the copayment for the duplex scan. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a duplex scan on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $100 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a duplex scan on July 10, 2020. You have been asked to pay a $100 copayment for the duplex scan. the duplex scan falls within the Outpatient diagnostic tests 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 duplex scan provided on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of indwelling ureteral stent by cystoscopy and cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor.

You asked the Plan to pre-approve removal of indwelling ureteral stent by cystoscopy and cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor. 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 removal of indwelling ureteral stent by cystoscopy and cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor. 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 benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. Treatment with tamsulosin and Myrbetriq has not been effective. The safety and efficacy of prostatic urethral temporary implant insertion for lower urinary tract symptoms caused by BPH is insufficient and lacking quality. As such, further research is needed in the form of quality randomized controlled trials. The iTind procedure is not endorsed by the American Urological Association Guidelines. 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 removal of indwelling ureteral stent by cystoscopy and cystourethroscopy,with insertion of temporary prostatic implant/stent with fixation/anchor have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of indwelling ureteral stent by cystoscopy and cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950).
You asked the Plan to pre-approve a core buildup. You say that you disagree with the Plan's denial of the service. The Plan denied your request. The Plan says the service at issue is not 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 a core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device (E0652).

You asked the Plan to provide a pneumatic compression device. You say that the enrollee needs a pneumatic compression device for lymphedema.The Plan denied your request. The Plan says the information provided indicates the enrollee has swelling only in the legs.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has lymphedema extending into the chest, trunk and/or abdomen.Therefore, we decided that the Plan does not have to provide a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical condition did not meet medical necessity criteria.
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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you inject insulin once daily and is not using an insulin infusion pump. The elements of the coverage
criteria 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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve the FreeStyle Libre continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, E2311, E2313, E2377).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.

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 accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee needs these additional accessories for the power wheelchair (E2300, E2311, E2313, E2377) as records document that the enrollee's upper extremity strength and function are adequate to control the power options using their own switches. He is reported to be independent with feeding and grooming and records document 5/5 bilateral upper extremity strength.

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 additional accessories for a power wheelchair (E2300, E2311, E2313, E2377).