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

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on January 1, 2020.You asked the Plan towaive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that you are responsible for the copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for one-way trip for emergency ambulance services and non-emergency ambulance services. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way trip for emergency ambulance services and non-emergency ambulance services 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 ambulance transport provided on January 1, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 30, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forMagnetic Resonance Imaging (MRI) of the brain (70553) and Computed Tomography (CT) of the brain (70450) provided November 20 and December 6, 2019. You asked the Plan to waive the copayments forthe radiology services. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct copayments were 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 $200 copayment for Complex Radiology. You have been asked to pay two $200 copayments for the radiology services. These services fall within the Complex Radiology 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 copayments forMagnetic Resonance Imaging (MRI) of the brain (70553) and Computed Tomography (CT) of the brain (70450) provided November 20 and December 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional Ketamine treatments.
You asked the Plan to pre-approve 6 additional Ketamine treatments. You say that the 6 additional Ketamine injections are medically necessary. The Plan denied your request. The Plan says the 6 additional Ketamine injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 6 additional Ketamine treatments. Our reviewer says that the 6 additional Ketamine injections are not medically necessary. Our physician reviewer found this enrollee has been treated for years for depression with only limited relief. She was referred for injections with the hopes of improvement. The enrollee has been unable to find an in network provider. The provider has stated that the referral was for IV infusion of Ketamine. The provider has had good results with patients where they were able to return to a better life. This enrollee had been approved for 9 injections of Ketamine infusion for the treatment of major depressive disorder, recurrent, moderate from January 20, 2020 until July 24, 2020. The provider has asked for an additional 6 Ketamine treatments claiming this enrollee had previously received approval for 9 injections. Based on review of the records and review of recent literature, this procedure is not indicated by the FDA for the treatment of Major Depressive Disorder, Recurrent or Other Specified Anxiety Disorder. The use of this procedure is considered off label as intranasal ketamine is approved by the FDA, Spravato (esketamine) when used in conjunction with oral antidepressant medication. Based on review of the records provided and the recent literature from the FDA, this procedure is not considered medically necessary for the treatment of Major Depressive Disorder, Recurrent, Moderate and Other Specified Anxiety Disorder and is not considered medically necessary due to no FDA indication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional Ketamine treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional Ketamine treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because the member presented with their Medicare card. The Plan denied your request. The Plan says the services were rendered out-of-network and were non-urgent/emergent.
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 has network providers available who can provide 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 the medical services provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor and implantable wireless pulmonary artery pressure sensor (CardioMEMS).You asked the Plan to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor and implantable wireless pulmonary artery pressure sensor. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not a covered benefit.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 transcatheter implantation of wireless pulmonary artery pressure sensor and implantable wireless pulmonary artery pressure sensor. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has heart failure with reduced ejection fraction and is on a good but complex medical regimen with control of blood pressure. The enrollee has had a number of recurrent hospital admissions for severe congestive heart failure. In this situation, a CardioMEMSPA pressure monitoring device has been shown to reduce recurrent hospitalizations when used with close monitoring in order to closely titrate diuretic and other medical therapy based on PA pressures. The Champions trial showed a significant reduction in hospital readmissions in patients with reduced ejection fraction and recurrent congestive heart failure who were monitored and treated based on information provided by the CardioMEMSdevice to their care providers. In this specific clinical instance, the CardioMEMSdevice is therefore appropriate and medically necessary, it meets Medicare criteria for coverage as safe and effective for the condition being treated and there is randomized published data to support its use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcatheter implantation of wireless pulmonary artery pressure sensor and implantable wireless pulmonary artery pressure sensor have been met.Therefore, we decided that the Plan has to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor and implantable wireless pulmonary artery pressure sensor (CardioMEMS).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation at the right C3-4 and C4-5.
You asked the Plan to pre-approve a repeat radiofrequency ablation. 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 a repeat radiofrequency ablation. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is being treated for cervical pain. The enrollee has undergone right C3/4 and C4/5 medial branch blocks on February 3, 2020 for cervical spondylosis. The enrollee reported minimal relief of the neck pain with 100% relief of the occipital headache. The enrollee had also undergone right cervical medial branch blocks on January 20, 2020 with 40% relief and with excellent relief of headaches. Radiofrequency ablation without positive diagnostic medial branch blocks is not considered the standard of care. 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 a repeat radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat radiofrequency ablation at the right C3-4 and C4-5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on January 10, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never been charged for these items before this. The Plan denied your request. The Plan says that you are responsible for the coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay a 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the prosthetic devices and medical 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 coinsurance for the ostomy supplies provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories for the enrollee.
You asked the Plan to pre-approve the requested items. You say that the enrollee is mentally and physically capable to use a group 3 power wheelchair. The Plan denied your request. The Plan says there is no indication that the enrollee can use the requested wheelchair safely and independently.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if 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. 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 items. Our physician reviewer found that the enrollee has Parkinson's and trigeminal neuralgia. She exhibits functional decline. She has had a group 2 power mobility device for about 14 months. She has poor lateral support and has fallen out of her chair multiple times. The records do not substantiate the enrollee is able to safely, physically manipulate a group 3 PMD. As such, this request is not 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 the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) and a consultation (D9310) with an oral surgeon. You asked the Plan to pre-approve the dental services. You say that the enrollee has 2 teeth that are completely dead. You say that the enrollee needs them to be extracted. You say that the teeth cannot be extracted by a general dentist because the enrollee is on a blood thinner. You also say that the enrollee could bleed to death if the service are not performed by an oral surgeon. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by an oral surgeon are not covered. The Evidence of Coverage clearly states that services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) and a consultation (D9310) with an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the yellow fever vaccine you received on December 5, 2019.You asked the Plan to pay for the vaccine. You say that you should be reimbursed for the vaccine.The Plan denied your request. The Plan says this vaccine is not covered under Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay forthe yellow fever vaccine you received on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 26, 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 the claim was not billed correctly.
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 file shows that the claims were billed with an outpatient POS
code while the enrollee was under inpatient status. 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 rendered to the enrollee on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forclinic visit. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with 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 has network providers available whocan provide 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 forthe medical services provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe defibrillator surgery and laboratory work provided from August 5, 2019 and August 8, 2019.You asked the Plan to waive the cost share forthe defibrillator surgery and the laboratory work. You say that you should not be responsible for the bill.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 20% coinsurance for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges and a $15 copayment for Medicare-covered in-network lab services. You have been asked to pay a totalof $729.94 for the defibrillator surgery and the laboratory work. The defibrillator surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The laboratory work 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 cost share forthedefibrillator surgery and the laboratory work provided from August 5, 2019 and August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar Vertiflex Interspinous Spacer.You asked the Plan to pre-approve Lumbar Vertiflex Interspinous Spacer. 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 Lumbar Vertiflex Interspinous Spacer. 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 diagnoses of lumbar radiculopathy, lumbar spinal stenosis, and chronic pain syndrome. The requested device is considered experimental. More research is needed. 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 Lumbar Vertiflex Interspinous Spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve LumbarVertiflex Interspinous Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you fort he Elan SRE 3000 Indoor Straight Stairlift purchased on November 20, 2019.You asked the Plan to reimburse you forthe stair lift. You say that you could not get up the stairs anymore and this company came within two days.The Plan denied your request. The Plansays this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to reimburse you forthe Elan SRE 3000 Indoor Straight Stairlift purchased on November 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on February 3, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to you by an out-of-network provider on February 3, 2020.