Persius/hicric huggingface dataset:
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 the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on September 13, 2018.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 procedure code 51785 is not supported.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 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique.We find that CPT code 51785 is not supported in the medical record. Specifically, the records do not include documentation of needle EMG of anal or urethral sphincter using any technique. 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 enrollee on September 13, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0425 and A0427) provided on
June 4, 2019.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare says ambulance claims need to be edited to assure the
presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue
code 540. The file shows that the claim was not billed with either a QM or QN modifier. Therefore, we decided
that the Plan does not have to pay for the ambulance services (A0425 and A0427) provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on May 20, 2019.
You asked the Plan to pay for the services. You say that you were taking care of your sister. 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 you by an out-of-network provider on May 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jaco V2 robotic arm.
You asked the Plan to pre-approve Jaco V2 robotic arm. You say that this equipment is needed for medal
purposes and is not a convenience item. This equipment would have no use for someone without a disability.
The Plan denied your request. The Plan says the requested item is not a covered benefit by the plan.
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 Jaco V2 robotic arm. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found while this device may assist with their ADLs, it cannot otherwise be concluded that it
is not otherwise for the convenience of the enrollee (and/or their caregivers). The functions of the device
largely appear to assist caregivers in reducing the performance of other duties. Furthermore, given the relative
novelty of this technology, the use of such a device is not readily consistent with the standards of care or
practice at this point in time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Jaco V2 robotic arm have not been met. Therefore, we decided that the Plan
does not have to pre-approve Jaco V2 robotic arm.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to enrollee from April 29, 2019 to June 19, 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 services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to enrollee from April 29, 2019 to June 19, 2019.Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee arthroplasty (27447) provided on April 10, 2019.
You asked the Plan to pay for the knee arthroplasty. You say that this licensed surgical assistant is the first assistant on this case and the one who should have been paid for this procedure. The Plan denied your request. The Plan says this service exceeds the maximum number allowed per day.
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 a knee arthroplasty (27447) provided on April 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 20, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's services provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring
system.
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that the enrollee needs
a continuous glucose monitor and supplies The Plan denied your request. The Plan says there is no
documentation the enrollee is testing at least 4 times per day or has had frequent adjustments to the treatment
regimen based on glucose testing.
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 does not show frequent adjustments of insulin or that the
enrollee has been testing four or more times a day. Based on this information, we decided that Medicare rules
for coverage of a continuous glucose monitor and supplies have not been met. Therefore, we decided that the
Plan does not have to pre-approve a continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve porcelain crown replacement (D2750) teeth 8 and 9.
You asked the Plan to pre-approve porcelain crown replacement. You say that teeth 8 and 9 are decaying and replacement of the crowns are medically necessary. The Plan denied your request. The Plan says that replacement of the crowns are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve porcelain crown replacement. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the presence of recurrent caries under existing crowns meets the criteria for coverage for the removal of the crowns to treat the caries and to replace the crowns with new restorations since in most cases crowns have to be cut off thus rendering them useless. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of porcelain crown replacement have been met. Therefore, we decided that the Plan has to pre-approve porcelain crown replacement (D2750) teeth 8 and 9.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza capsules.
You asked the Plan to pre-approve Amitiza capsules. You say that the enrollee needs this medication. The Plan denied your request. The Plan says this medication is only covered under Medicare Part D.
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 pre-approve Amitiza capsules.
Benefits for Amitiza capsules 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraocular lens procedure you received from June 12, 2018, to July 24, 2018.
You asked the Plan to pay for the services. You say that the procedure did not work. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a standard intraocular lens (IOL), but there is an additional fee for a presbyopia-correcting IOL.
We looked at the file and the Plan's rules. The records show that you were provided a presbyopia-correcting IOL. The plan does not cover this type of lens. You are responsible for any additional fees over the cost of the standard IOL. Based on this information, we decided that you have been asked to pay the correct amount. Therefore, we decided that the Plan does not have to pay for the intraocular lens procedure you received from June 12, 2018, to July 24, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery provided on October 31, 2019.You asked the Plan to waive the copayment for the cataract surgery. You say that you have paid this in full and would like reimbursement. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $190 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $190 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the place of service was an ambulatory surgical center.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 cataract surgery provided on October 31, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the albuterol and hydrocodone-acetaminophen provided on September 4, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not covered by the Plan.
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 albuterol and hydrocodone-acetaminophen provided on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 31, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were informed that no
copayment was required. 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 $250
copayment for advanced imaging services at an in-network outpatient hospital.
You have been asked to pay $107.70, which is less than the standard $250 copayment for the CT scan. The CT
scan 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 copayment for the CT scan provided on October 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography with positive airway pressure (PAP) titration (95811).You asked the Plan to pre-approve polysomnography with PAP titration. You say that this is medically necessary.The Plan denied your request. The Plan says this is not necessary because an automatic positive airway pressure (APAP) machine is supported for the enrollee.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 polysomnography with PAP titration. Our reviewer says that the requested service isnot considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been diagnosed with obstructive sleep apnea. A reasonable approach to treatment would be initiation of continuous PAP with an auto-titrating device, which would not require a formal titration study. The titration study is therefore considered 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 polysomnography with PAP titration have not been met.Therefore, we decided that the Plan does not have to pre-approve polysomnography with positive airway pressure (PAP) titration (95811).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip x-ray (73501) provided on August 26, 2019.You asked the Plan to pay for the hip x-ray. You say that the member received multiple services on the same date of service. The Plan denied your request. The Plan says this service is included in another service provided at the same time by the same provider.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 code 73501 is not supported in the record. Specifically, CPT code 73501 has a bundled relationship and is the column II code to approved CPT code 73502.  Based on this information, we decided that Medicare rules for coverage of the hip x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a hip x-ray (73501) provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the 14 extractions and two alveoloplasties in conjunction with extractions provided on September 19, 2019.You asked the Plan to pay more for the extractions and alveoloplasties. You say that you cannot afford this amount or a payment plan.The Plan denied your request. The Plan says the dollar amount in dispute is above and beyond the maximum benefit allotted for the year. The Plan also says that services beyond your annual benefit maximum are of your own financial responsibility.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 Plan offers a $500 annual dental benefit maximum. The contract also says that you pay a $50 deductible for supplemental comprehensive dental services. The record shows that you met the annual deductible benefit on September 19,2019 and your annual deductible benefit had been exhausted.Therefore, we decided that the Plan does not have to pay more for the 14 extractions and two alveoloplasties in conjunction with extractions provided on September 19, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (code D0210) provided on May 7, 2019.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you should not need to pay for this service. The Plan denied your request. The Plan says this service has a limit to how often it can be paid in three years. The Plan also says that this limit had already been reached.
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, intraoral complete series (including bitewings) are limited to once every 36 months. The record shows that you received a complete series of intraoral x-rays on August 23, 2016 and your intraoral complete series benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (code D0210) provided on May 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rytary for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary for the enrollee.
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered  on September 3, 2019.