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

We decided that the Plan has to pre-approve an MRI of the neck.
You asked the Plan to pre-approve an MRI of the neck. You say that the requested MRI of the neck is medically necessary. The Plan denied your request. The Plan says that the requested MRI of the neck is not medically necessary.
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 an MRI of the neck. Our reviewer says that the requested MRI of the neck is medically necessary. Our physician reviewer found this enrollee presents with complaints of intermittent headaches and numbness into the bilateral upper extremity, exacerbated with cervical flexion. Clinical exam findings do not evidence any focal neurologic deficits. There is CT scan evidence of multilevel severe disc osteophyte complexes with neuroforaminal encroachment and cord impression at the C3/4 and C4/5 levels. There is electrodiagnostic evidence of bilateral carpal tunnel and cubital tunnel syndrome, as well as nerve root irritation. Under consideration is a request for MRI of the neck without contrast. The physician has requested this imaging study to further evaluate her symptoms and as a requirement for referral to a spine surgeon. Current evidence based medical guidelines would support MRI as an appropriate study to evaluate the cervical spine in the setting of neural impingement and for potential surgical planning. Therefore, this request for MRI of the neck without contrast is medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the neck have been met. Therefore, we decided that the Plan has to pre-approve an MRI of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on October 23, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Review of the file shows that the documentation submitted did not include a Proof of Delivery, or a Delivery Ticket.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you have a broken bone and need to see your doctor more often than usual.The Plan denied your request. The Plan says that the request exceeds the transportation benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of sixteen (16) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips.
Appeal type: Testing
Decision: Favorable

We decided thatthe Plan has to reduce the copayment forthe cystoscopy provided on February 19, 2020.You asked the Plan to reduce the copayment forthe cystoscopy. You say that you have never had a diagnostic test and procedure copayment for this procedure before. You say you would like the procedure to reflect a $40 copayment for a specialist's visit. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $40 copayment for each specialist in-person office visit. The Plan says you must pay a $50 copayment for the cystoscopy. Based on the Plan contract, however, you cannot be asked to pay more than a $40 copayment for the cystoscopy. The record shows the cystoscopy is a surgical service that was provided by a specialist. Therefore, we decided that the Plan has to reduce the copayment forthe cystoscopy provided on February 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric care provided on October 15, 2019.
You asked the Plan to pay for the psychiatric care. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychiatric care provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on November 14, 2019.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that you don't understand the increase in cost. You say that this is a mistake. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. The enrollee has been asked to pay $1,476, which is less than the standard 20% coinsurance for the leuprolide acetate suspension. The leuprolide acetate suspension falls within the "Medicare Part B prescription drugs" 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 when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (cast metal framework with resin denture bases) and an occlusal guard.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit for dentures has been exhausted, and the occlusal guard 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. The records show that dentures were last received less than five years ago on December 18, 2019. Additionally, there is no specifically mentioned benefit for the occlusal guard. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (cast metal framework with resin denture bases) and an occlusal guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulation device (E0766) to be provided from an out-of-network durable medical equipment supplier with in-network benefits.
You asked the Plan to pre-approve the electrical stimulation device. You say that this is the best FDA approved option at this time for treating the enrollee's recurrent glioblastoma. The Plan denied your request. The Plan says that treatment for recurrent glioblastoma is not covered. The enrollee has recurrent glioblastoma, not newly diagnosed disease and does not meet the criteria.
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 the electrical stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical stimulation device (E0766) to be provided from an out-of-network durable medical equipment supplier with in-network benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided on January 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision care provided on July 12, 2019. You asked the Plan to waive the deductible for vision care. You say that you disagree with the denial of charges. The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible for out-of-network vision care. You received vision care on July 12, 2019 with an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network charges. The record shows that you had only paid $588.76 toward the $975 deductible. Therefore, you are responsible to pay the allowed amount of $125.82. The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for out-of-network vision care. This cost sharing is a contractual obligation that had not been met at the time vision care was received on July 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for vision care provided on July 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services. There are no complex wounds, no enteral feedings, IV antibiotics or other skilled level need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on September 26, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flat bottom cane.You asked the Plan to pre-approve a flat bottom cane. You say that you need a flat bottom cane to avoid falls. The Plan denied your request. The Plan says you are approved for a quad/3-prong cane but a flat bottom cane is a convenience item. 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. You have been provided a Medicare approved cane. Based on this information, we decided that Medicare rules for coverage of a flat bottom cane have not been met. Therefore, we decided that the Plan does not have to pre-approve a flat bottom cane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (CPT 88120) provided on December 11, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services (CPT 88120) provided on December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that you would like reconsideration because this drug is
medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the
member does not meet step-therapy exception criteria.
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
documentation does not support that Orthovisc and Monovisc have been tried and failed. Our physician
reviewer found the documentation does not support that Monovisc and Orthovisc would likely be less effective,
and/or would likely have adverse effects. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on November 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not eligible for payment of assistant surgeon services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for out-of-network (OON) heart surgery (C9602) provided on November 27, 2019 to November 28, 2019. You asked the Plan to waive the cost-sharing for OON heart surgery. You say that you cannot afford this charge. The Plan denied your request. The Plan says this processed 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 50% coinsurance of the Medicare-allowed amount after the $950 yearly out-of-network deductible for out-of-network outpatient surgery services. The rules also say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. You have been asked to pay $7,581.69 for out-of-network heart surgery. The allowed amount for this service was $14,242.19. The record shows that you had $921.19 remaining of your deductible. After the deductible is applied, you are responsible for a 50% of the remaining allowed amount ($13,321), $6,660.50, for a total cost-share of $7,581.69. 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. You are also responsible for the cost of self-administered drugs, $153, for a total responsibility of $7,734.69. Therefore, we decided that the Plan does not have to waive the cost-sharing for out-of-network (OON) heart surgery (C9602) provided on November 27, 2019 to November 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D4342, D4921, D4381, D9630) provided
September 23, 2019.
You asked the Plan to pay for the Dental services. You say that the Dental services should be covered and are
medically necessary. The Plan denied your request. The Plan says the benefit for scaling and root planing
(D4342) was already exhausted for this benefit period. The remaining services are not covered benefits.
Insufficient medical records were provided to support the necessity of the requested services.
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. Scaling and Root Planing (D4342) is limited to one procedure per
calendar year. A procedure was already paid during 2019. The remaining services- gingival irrigation (D4921),
localized delivery of antimicrobial agents (D4381), and drugs dispensed in the office for home use (D9630) are
not covered benefits under your dental plan. Therefore, we decided that the Plan does not have to pay for dental
services (D4342, D4921, D4381, D9630) provided September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring
System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee would benefit from
a CGM to improve glycemic control and safety. The Plan denied your request. The Plan says the enrollee is not
on a short-acting insulin.
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. The record shows the enrollee is not insulin treated, by injection or
pump, three or more times a day. 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 preapprove
a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on November 14, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you should only be responsible for a $40 copay. The Plan denied your request. The Plan says you received dental services from an out-of-network dentist.
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. Review of the file show that you received prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) on November 14, 2019 by an out-of-network provider. The cost share was applied correctly. Since the provider is out-of-network, the plan pays according to a maximum allowable fee schedule and the member is responsible for all fees in excess of this amount from the billed amount. As per the dental rider benefits, since the provider was out-of-network, the difference of billed amount and allowed amount also became member's responsibility. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on November 14, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services coded Q4186 provided on November 27, 2019.
You asked the Plan to pay for the services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 Q4186 is epifix, per square centimeter. We find that CPT code Q4186 is not supported in the medical record. Specifically, the documentation submitted did not include documentation to support the 11 units that were billed. 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 services coded Q4186 provided on November 27, 2019.