Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a catheter implantation procedure for intrathecal or epidural drug infusion.
You asked the Plan to pre-approve a catheter implantation procedure for intrathecal or epidural drug infusion. You say that the enrollee needs a catheter implantation procedure for intrathecal or epidural drug infusion for pain management. The Plan denied your request. The Plan says the enrollee has an implanted programmable device and cannot have another.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a catheter implantation procedure for intrathecal or epidural drug infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a catheter implantation procedure for intrathecal or epidural drug infusion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on September 17, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitteddid not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP battery backup.
You asked the Plan to pre-approve a CPAP battery backup. You say that your home was affected by the earthquakes and on many occasions you have no electricity. The Plan denied your request. The Plan says the supplier must ensure there is an appropriate and acceptable contingency plan to address any emergency situation or mechanical failures of the equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. Medicare will not pay separately or make any additional payment for backup equipment. Therefore, we decided that the Plan does not have to pre-approve a CPAP battery backup.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forshoulder arthroscopy surgery services provided on January 9, 2019.You asked the Plan to pay forthe shoulder arthroscopy surgery services. You say that the medical records provided support the surgery services billed.The Plan denied your request. The Plan says the records provided do not support the service in dispute.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 29820 is arthroscopy, shoulder, surgical; synovectomy, partial.  We find that CPT code 29820 is not supported in the medical record. Specifically, the description of services in the operative note did not match those required by the NCCI for the CPT code in dispute. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroscopy surgery services have not been met.Therefore, we decided that the Plan does not have to pay forshoulder arthroscopy surgery services provided on January 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve more than 12 PT visits.You asked the Plan to pre-approve more than 12 PT visits. You say that you need the outpatient physical therapy services.The Plan denied your request. The Plan says more than 12 PT visits is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 more than 12 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional 6 PT visits do not meet coverage criteria. The therapist has had adequate time to safely transition you to a home exercise program. Additional visits beyond the 12 already approved by the plan are not reasonable and necessary. The chart notes do not support that the requested services have the inherent complexity and sophistication to require the skills of a licensed professional with specialized training and experience for safe and effective delivery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of more than 12 PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve more than 12 PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you do not want to prick your finger and your doctor told you about this device. The Plan denied your request. The Plan says you are not insulin-treated.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. You are not insulin injecting and you do not have an insulin pump. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveclinic visits to be provided by Out of Network (OON) Provider. You asked the Plan to pre-approveclinic visits. You say that the clinical notes will support the need for services.The Plan denied your request. The Plan says the Out of Network Provider was aware they are not an in-network provider for Plan as of October 1, 2019. The clinic continued to treat the member and did not contact Plan until December 9, 2019 when Out of Network (OON) Provider requested a prior authorization for out-of-network coverage.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 clinic visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although ongoing treatment with methadone and monitoring was needed to be completed by a pain specialist, there was no indication from the provided records that switching to an in-network pain specialist would increase risk or cause disruption in treatment. There were no exceptional circumstances or new treatments or procedures which would not be appropriate for a different treating physician to provide. Therefore, based on the provided records, the enrollee's condition does not warrant ongoing care with Out of Network (OON) Provider, and it would be safe to transition to an in-network provider.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of clinic visits have not been met.The record shows that the Plan provided you with a list of in-network physicians that can provide you with the needed services. Therefore, we decided that the Plan does not have to pre-approve clinic visits to be provided by Out of Network (OON) Provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea manual wheelchair.You asked the Plan to pre-approvea manual wheelchair. You say that you need this to go to the bathroom and shower and to go to the doctor.The Plan denied your request. The Plan says that you have recently received a power wheelchair.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as a manual wheelchair.Therefore, we decided that the Plan does not have to pre-approvea manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the problem focused limited oral evaluation (code
D0140) provided on September 12, 2019.
You asked the Plan to hold you harmless for the problem focused limited oral evaluation. You say that you did
not realize there had to be a certain time from one set of x-rays to another. You also say that you are on a
limited income and cannot afford to see another dentist. The Plan denied your request. The Plan says that this
service is part of another benefit you had done.
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. The Plan covers the problem
focused limited oral evaluation when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The EOC clearly states that you have a $750.00 allowance for
comprehensive dental services every quarter. The contract does not specifically say what comprehensive
services this quarterly allowance can be used for. Based on this information, we decided that the Plan's rules for
coverage of the problem focused limited oral evaluation have been met. Therefore, we decided that the Plan has
to hold you harmless for the problem focused limited oral evaluation (code D0140) provided on September 12,
2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammogram or the ultrasound provided on November 19, 2019.You asked the Plan to waive the copayment forthe diagnostic mammogram and the ultrasound. You say that you were told the diagnostic mammogram was covered and a copayment was not mentioned. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $40 copayment for the diagnostic mammogram and a $40 copayment for the ultrasound. The diagnostic mammogram and the ultrasound fall 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 forthe diagnostic mammogram or the ultrasound provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 17, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 12, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentationsubmitted did not include a valid physician order/lab requisition.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at thefile and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain documentation of the ordering physician's intent that the tests be performed.Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on July12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea laparoscopic sleeve gastrectomy and upper gastrointestinal endoscopy for the enrollee.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee's comorbidities are not clearly attributed to obesity, and has been successful with medical treatment for obesity.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 requested services. Our physician reviewer found that the enrollee needs to document mass index greater than or equal to 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This enrollee has a BMI that is less than35 kg/m2, most recently at 34 kg/m2. The file does not document any medical chart notes showing medical treatment for obesity. Medical necessity is therefore not determined at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approvea laparoscopic sleeve gastrectomy and upper gastrointestinal endoscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that orthotics might relieve your back pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a knee meniscectomy.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a historyof persistent left medial knee pain with associated mechanical symptoms and swelling. Functional limitations have been documented with activities of daily living. Clinical exam findings have been consistent with imaging evidence of a complex medial meniscus tear and degenerative arthritis. Current evidence based medical literature supports arthroscopic meniscectomy in the setting of degenerative changes when conservative treatment has failed and positive McMurray's signs are consistent with radiological findings. In this case, there is documentation of moderate to severe medial compartment osteoarthritis and consistently positive McMurray's test consistent with imaging evidence of a complex medial meniscus tear. Given the failure of long-term conservative treatment, proceeding with left knee meniscectomy would be considered the standard of care and medically reasonable and necessary for treatment of the enrollee's left knee condition.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvea knee meniscectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided from August 1, 2019 through August 29, 2019.You asked the Plan to waive the copayment forwound debridement. You say that you wouldn't have received the services if you knew the expenses. You say that the copayment is very high.The Plan denied your request. The Plan says the copayments applied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital.You have been asked to pay a total of $770.97 for wound debridement. Wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound debridement is considered aoutpatient surgical procedure. This means thatyou 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 forwound debridement provided from August 1, 2019 through August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on April 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on July 31, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power mobility device.You asked the Plan to pre-approvea scooter. You say that you cannot get around outside of your house with a basic wheelchair.The Plandenied your request. The Plan says the records indicate you are able to get around inside your home with a walker and your home cannot accommodate a scooter.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, and you cannot safely operate the PMD being requestedin your home.This means that Medicare rules for coverage of a PMD have not been met.The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home.Therefore, we decided that the Plan does not have to pre-approvea Group 1 power mobility device.