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

We decided that the Plan does not have to pay for the chest x-ray provided on December 1, 2020.
You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says this is not covered for screening purposes.
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 test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99214) provided
August 30, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told you didn't owe
anything, and the copayment should be waived. The Plan denied your request. The Plan says the correct
copayment was 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 $35
copayment for urgent care services.
You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the
urgent care 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 for an urgent care visit
(99214) provided August 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weight scale (E1399).

You asked the Plan to pre-approve a scale. You say that your PCP advised you that you need to make sure your feet aren't getting swollen and you are not rapidly gaining weight or water so you need the scale. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested service as there is no documentation of the enrollee receiving dialysis.

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. Weight scales are needed for patients who have kidney failure and need dialysis. There is no documentation in the files that the enrollee has kidney failure or needs dialysis. Based on this information, we decided that Medicare rules for coverage of the scale have not been met. Therefore, we decided that the Plan does not have to pre-approve a weight scale (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital due to an acute schizophrenic episode. He was found to have osteomyelitis and bony destruction of the third and fifth digits on the left foot. He underwent amputation of digits two through five of the left foot. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided from September 18, 2020, through October 2, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that the plan does not have a copayment for days 1-20. You say that the claim was processed incorrectly. The Plan denied your request. The Plan says the copayment 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 $275 copayment each day for days 1 to 5 for in-network, Medicare-covered hospital care. $0 copayment for additional Medicare-covered days. You have been asked to pay a $1,375 copayment for the inpatient rehabilitation stay. ($275/day x first 5 days = $1,375). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" 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 inpatient rehabilitation stay provided from September 18, 2020, through October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eyelea.

You asked the Plan to pre-approve Eyelea. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Eyelea. Our reviewer says that the documentation does not support that the enrollee meets step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Tributary (branch) retinal vein occlusion in the left eye, with macular edema. The documentation does not support that the enrollee has tried and failed Bevacizumab. The documentation does not support that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eyelea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eyelea.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on December 4, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you believe these drugs should be covered. The Plan denied your request. The Plan says self-administered drugs are never covered by Medicare and are an exclusion in your Evidence of Coverage contract under Part B benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on December 4, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two unspecified preventative procedures (D1999) provided on October 22, 2020 and November 18, 2020.
You asked the Plan to pay for the unspecified procedures. You say that the Plan should cover these services because you were led to believe that this provider was in-network. The Plan denied your request. The Plan says that they have agreed to cover most of the services from the dates in question as a one-time exception due to a misunderstanding. However, the unspecified preventative procedures are not covered by Medicare or by the Plan's supplemental dental benefit, even when provided in-network.
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 two unspecified preventative procedures (D1999) provided on October 22, 2020 and November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says outpatient services can be offered as an alternative.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. There is no documentation of skilled nursing or skilled therapy. You appear to be functioning at or near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray and hand x-ray provided on August 18, 2020.
You asked the Plan to pay for the chest x-ray and hand x-ray. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on August 6, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray and
hand x-ray provided on August 18, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler.

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 that the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has known dilated cardiomyopathy and has not had a repeat echocardiogram. If the left ventricular ejection fraction has decreased further based on the echo, even in the absence of symptoms, more intensive guideline-directed therapy would be appropriate and likely change clinical management. The TTE is therefore reasonable and 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 has to pre-approve a transthoracic echocardiogram (TTE) with Doppler.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on October 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown, core buildup, including any pins when
required, and maxillary partial denture.

You asked the Plan to pre-approve the crown, core buildup, and maxillary partial denture. The Plan denied
your request. The Plan says crown and core buildup are not covered benefits. The Plan also says that the
enrollee's maxillary denture benefit has been exhausted.

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, crown and core buildup are not among
those covered under this benefit. The contract says that the enrollee is limited to 1 complete or partial denture
every 5 years. The record shows that the enrollee received a maxillary partial denture on June 30, 2020, and the
enrollee's maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to
pre-approve a crown, core buildup, including any pins when required, and maxillary partial denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided July 28, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim did not include a valid place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80307, & G0483 are not supported in the medical record. Specifically, the claim
showed place of service 81, laboratory, however the records show the specimen was obtained in the office
setting (place of service 11). Based on this information, we decided that Medicare rules for coverage of the lab
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307,
G0483) provided July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation, prophylaxis, 2 amalgam fillings, the unspecified preventive service, and 2 resin based fillings provided from September 23, 2020, to October 15, 2020.

You asked the Plan to pay for the dental services. You say that you were unaware that the provider was out of network. You also say that you were advised it was your responsibility to make sure they were in network with the health plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive out of network are not covered.

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 that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation, prophylaxis, 2 amalgam fillings, the unspecified preventive service, and 2 resin based fillings provided from September 23, 2020, to October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of dextroscoliosis of the lumbar spine with no documentation of the Cobb angle. Evidence of potential instability associated with the retro/spondylolisthesis is not detailed. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 9, 2020.
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the dental services are not supported in the medical record. Specifically, the claim for these services was submitted without a diagnosis code, which is necessary for claims processing. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the second opinion to be provided by the requested out-of-network provider. You say that you have been diagnosed with lung cancer. You say you would like to go to this provider for a second opinion and for the chance of participating in any clinical trials or experimental treatments. The Plan denied your request. The Plan says services are available through Plan contracted and designated providers. The services are available locally.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by the requested out-of-network provider.