Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) and the application of hot or
cold packs (97010) provided by a chiropractor.

You asked the Plan to pay for electrical stimulation and the application. You say that these services should be
covered. The Plan denied your request. The Plan says these services are not covered when provided by a
chiropractor.

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 electrical stimulation (G0283) and the application of hot or cold packs
(97010) provided by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 physician's services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services (A0429 and A0425).

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this was a separate service that was billed correctly. The Plan denied your request. The Plan says that modifier 59 is not appropriate in this case.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT codes A0429 and A0425 are supported in the record. Specifically, the record indicates that this provider rendered multiple trips to the same beneficiary on the same date of service. Modifier 59 indicates that these services were separate and distinct from one another. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services (A0429 and A0425).

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider.

You asked the Plan to waive the copayment for an ultrasound. You say that you believe this should be covered 100%. The Plan denied your request. The Plan says the correct copayment has been 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 $25 copayment for outpatient diagnostic tests/diagnostic tests.

You have been asked to pay a $25 copayment for an ultrasound. The correct copayment has been applied to the services provided. An ultrasound falls within the outpatient diagnostic tests/diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.

You asked the Plan to pre-approve the monitor. You say that this would help monitor fluctuations. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for bariatric surgery.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the request for inpatient status does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found this is an outpatient or ambulatory procedure and acute inpatient admission is not clinically warranted. Conversion to gastric bypass is not medically necessary at this time as the enrollee does not meet CMS/NCD criteria for bariatric surgery with a BMI that is less than 35 at this time. Conversion to gastric bypass and inpatient admission is not determined to be 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission for bariatric surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are a double amputee and unable to get to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram for the enrollee.

You asked the Plan to pre-approve the echocardiogram. You say that this is medically necessary. The Plan denied your request. The Plan says there are no symptoms, and medical conditions are stable.

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 echocardiogram. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the patient has known coronary disease but no valve disease, no documented cardiac symptoms, no documented cardiac abnormalities on physical exam and no documented ECG changes. In this circumstance of a clinically stable patient with no active cardiac disease the documentation does not support the medical necessity for a repeat echocardiogram. Coverage criteria are not met and current guidelines also do not consider a repeat echocardiogram appropriate in this setting. 

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 echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound.

You asked the Plan to waive the copayment for the breast ultrasound. You say that you should not have a
copayment. 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 $55
copayment for Outpatient Diagnostic Tests.

You have been asked to pay a $55 copayment for the breast ultrasound. The breast ultrasound falls within the
Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the breast
ultrasound.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 further physical therapy (PT) visits.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says one visit is approved but 11 further are 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 these services. 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 records show that you have hip pain and difficulty walking. You are able to walk unlimited distances with minimal assistance. You do not need assistance for toilet transfers, car transfers, sitting to standing, or sitting to lying down. The requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for your condition and the documentation does not show that your functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The services are not part of a maintenance program and are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 11 further physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for Budesonide.

You asked the Plan to reduce the cost share for the requested drug. You say that you would like the cost decreased. The Plan denied your request. The Plan says the drug is not eligible for a lower copay.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. 

The requested drug 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 upon enrolling in the Plan. Medicare does not allow a cost reduction, or tier exception on Part B drugs. Therefore, we decided that the Plan does not have to reduce the cost share for Budesonide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the overdenture (D5865).

You asked the Plan to pay for the dental item. You say that you lost your teeth at a young age and need to wear dentures. You say that after about 10 years you are starting to have problems eating and with connecting joints. You say that you need both dentures to be replaced. You also say that you need both dentures in order to eat normally. The Plan denied your request. The Plan says overdenture is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the overdenture (D5865).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records contain discrepancies with the reported place of service noted on the submitted claim form.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 80307 and G0483 is not supported in the record. Specifically, this claim was billed with a laboratory place of service code, but the record indicates that the face-to-face service was rendered in an office setting. 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 (80307 and G0483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the orthosis. You say that please review provided documentation and process the
claim for payment as the enrollee is using the item and it is helping the enrollee. The Plan denied your request.
The Plan says The DME supplier did not present any medical records showing that the prescribing physician
ever say the enrollee.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
(L0650).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.

You asked the Plan to waive the copayment for the ambulance services. You say that you do not agree with the
cost share and would like to appeal. The Plan denied your request. The Plan says you were charged this cost
sharing 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 $200
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $200 for these
services. 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 ambulance services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Keytruda regimen.

You asked the Plan to pre-approve Keytruda pembrolizumab (J9271), palonosetron hcl (J2469) and fosaprepitant (J1453). You say that the enrollee is not eligible for surgery, radiation therapy or additional chemotherapy. The Plan denied your request. The Plan says that criteria for the requested regimen has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda pembrolizumab (J9271), palonosetron hcl (J2469) and fosaprepitant (J1453). Our reviewer says that the service is reasonable and medically necessary. Our physician reviewer found Pembrolizumab (Keytruda) is FDA approved for the treatment of unresectable or metastatic, tumor mutational burden-high solid tumors (TMB-H; =10 mutations/megabase [mut/Mb]; as determined by an approved test) in adult and pediatric patients who have progressed following prior treatment and have no satisfactory alternative treatment options. This patient has a TMB of 10.5 and, therefore, meets criteria as the notes also say the enrollee is not a candidate for other treatments after initial chemotherapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda pembrolizumab (J9271), palonosetron hcl (J2469) and fosaprepitant (J1453) have been met. Therefore, we decided that the Plan has to pre-approve a Keytruda regimen.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you feel that the denial of the claim is unjust
and the plan should pay to the policy limit as this cost would still be the cost under any circumstances. The
Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network
provider.

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 health plan contract on
page 83, specifically says that dental services must be received from a participating provider in order to be
covered by the plan.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
services provided from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0650).

You asked the Plan to pay for the back brace. You say that you would like reconsideration because the back brace is medically necessary. The Plan denied your request. The Plan says there is no evidence of a relationship between the member and ordering provider.

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 back brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the notes submitted do not support a back brace. The notes describe knee pain but there is no notation of the member's consent to a telmedicine visit.

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 back brace have not been met. Therefore, we decided that the Plan does not have to pay for the back brace (L0650).