Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided on April 8, 2021.
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on May 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a specialist office visit. You say that you would like the Plan to pay for this. You say that you went shooting with earplugs in and you became deaf. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that the member's primary care physician did not refer these services. The Plan says that there are in-network providers available for these services.

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 a specialist office visit provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the water vapor thermal therapy (53854).
You asked the Plan to pre-approve the water vapor thermal therapy. You say that you are requesting an appeal for the procedure. The enrollee's prostate range is within the approval range. The Plan denied your request. The Plan says the records do not show that the enrollee meets the 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 water vapor thermal therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the coverage criteria as above. Specifically, prostate size was not between 30-80 cc, maximum urinary flow rate (QMAX) of 15 mL/s (voided volume greater than 125 cc), and International Prostate Symptom Score was 13. 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 water vapor thermal therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the water vapor thermal therapy (53854).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula, nutritionally complete, for special metabolic needs (B4154).
You asked the Plan to pre-approve the enteral formula. You say that the enrollee is losing more than 10 pounds (lbs) in 2 months with 10 cans of Novasource per month. You say that the enrollee will benefit from a nutritional standpoint if taking in 2 cans per day for 30 days, or 60 cans per month. You also say that the enrollee will need this indefinitely and will be reassessed in 12 months. The Plan denied your request. The Plan says the requested nutritional supplement is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve enteral formula, nutritionally complete, for special metabolic needs (B4154).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer System.

You asked the Plan to pre-approve the Vertiflex Interspinous Spacer System. You say that you would like reconsideration because the requested device is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence in published peer-reviewed literature to support the use of interspinous spacers in the treatment of spinal stenosis.

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 Vertiflex Interspinous Spacer System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. 

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 Vertiflex Interspinous Spacer System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology consultation and report (88321) provided 
February 22, 2021. You asked the Plan to pay for the laboratory services. You say that please review the pathology report and 
reprocess for payment. The Plan denied your request. The Plan says the number of unites exceeds the Medicare 
medically unlikely edits. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed for 2 units of this 
code, exceeding the MUE. The plan paid for 1 unit of service for CPT code 88321. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical pathology consultation and report (88321) provided 
February 22, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for your condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 56-year-old female with malnutrition who is currently in an inpatient rehabilitation facility. In this case, there are identifiable skilled nursing service needs and identifiable skilled therapy service needs. However, you do not require these skilled nursing or therapy services on a daily basis. In conclusion, you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis (88374x3) provided on September
24, 2020.

You asked the Plan to pay for the morphometric analysis. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the additional units exceed Medicare's
MUE.

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 pay for the morphometric analysis. Our reviewer
says that the record shows that the Plan paid 5 units of this code. Our physician reviewer found the
documentation does not support that the additional 3 units were medically reasonable or 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 morphometric analysis have not been met. Specifically, CPT code 88374
has an MUE of 5 and an MAI of 3. The record shows that the Plan paid for 5 units of this service and our
reviewer determined that the documentation does not support an additional 3. Therefore, we decided that the
Plan does not have to pay for morphometric analysis (88374x3) provided on September 24, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the myocardial perfusion imaging, tomographic (SPECT) (78451). 
 
You asked the Plan to pre-approve the diagnostic service. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says that the records do not 
support that the enrollee meets the medically necessary Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 diagnostic service. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found although her chest pain is intermittent and relatively rare, she had evidence of apical 
ischemia on a prior nuclear stress test. Based on the applicable CMS criteria (LCD 33960) noted below she 
meets CMS indications for repeat nuclear stress testing to reassess any changes in the extent of the cardiac 
ischemia previously documented on the January 2021 stress nuclear scan. "Risk assessment or re-evaluation of 
disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease 
on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the 
past two years." 
 
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 diagnostic service have been met. Therefore, we decided that the Plan has to 
pre-approve the myocardial perfusion imaging, tomographic (SPECT) (78451).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from January 16, 2019, through January 19, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has 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 $295 copayment per day, for days 1-6 for inpatient hospital care. You have been asked to pay $885 ($295 copayment x 3 days) for the inpatient hospital care 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 waive the copayment for the inpatient hospital care provided from January 16, 2019, through January 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the provider diagnosed your condition. The Plan denied your request. The Plan says you do not have medical needs that must be met by an out-of-network doctor.

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 OON services. Therefore, we decided that the Plan does not have to pre-approve Botox injections to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 25, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you do not think you should have to pay this copayment because you had to wait in the ER for 7 hours. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for emergency room visits. You have been asked to pay a $65 copayment for the ER visit. This copayment applies regardless of how long it takes for you to be seen in the emergency room. 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 you had on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 19, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
You asked the Plan to pre-approve Vyzulta. You say that the enrollee has failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 Vyzulta.
Benefits for Vyzulta 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 pay for the panoramic x-ray (D0330) provided on May 4, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that the full mouth x-rays were medically necessary. The Plan denied your request. The Plan says you have exceeded your benefit for a panoramic x-ray.
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, full mouth series, periapical or panoramic x-ray are limited to once every 2 year period. The record shows that you received a panoramic x-ray on October 27, 2020 and your full mouth series, periapical or panoramic x-ray benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 16, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly. The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided April 13, 2021.
You asked the Plan to pay for the dental cleaning and periodic oral exam. You say that you believe you have dental coverage and do not understand why the services are not covered. The Plan denied your request. The Plan says you are not enrolled in optional supplemental dental benefits and therefore the routine dental services are not covered.
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 prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 23, 2020 and coded as 87496, 87498, and 87631. You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this lab service was ordered as a screening which is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, 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 lab services provided to the enrollee on November 23, 2020 and coded as 87496, 87498, and 87631.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the bitewing x-ray and palliative treatment provided on 
March 2, 2021. 
 
You asked the Plan to pay more for the bitewing x-ray and palliative treatment. You say that the doctor only 
saw you for one second and asked you to pay $59. The Plan denied your request. The Plan says the coinsurance 
applied correctly. 
 
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 Plan is only obligated to pay 50% 
coinsurance toward the bitewing x-ray and palliative treatment. Therefore, we decided that the Plan does not 
have to pay more for the bitewing x-ray and palliative treatment provided on March 2, 2021.