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

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion surgery.
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 submitted records show that you have degenerative low back pain. There is no documentation of SI joint instability, fracture, or lesion. The requested SI joint fusion is considered experimental for the treatment of your condition and is 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 sacroiliac (SI) joint fusion surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services.Our reviewer says that daily skilled services are not necessary. Our physician reviewer found themedical record shows you are medically unstable and not a candidate for skilled care in a skilled nursing facility. Admission to a SNF for inpatient skilled rehab or nursing services is not medically necessary.Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP machine purchased from a commercial vendor on March 30, 2020.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this equipment. The Plan denied your request. The Plan says you purchased equipment from a vendor is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program This equipment was purchased from a retail vendor who does not accept Medicare payment or insurance. Therefore, we decided that the Plan does not have to pay for a CPAP machine purchased from a commercial vendor on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 retainer crowns (D6752) and a pontic (D6242).You asked the Plan to pre-approvethe dental services. You say that you have been to 3 or 4 dental clinics and the services have been denied. You say that you need these services to support your teeth. You also say that the plan representative advised that you had $2,000 topay for crowns and other dental services.The Plan denied your request. The Plan says retainer crowns are not listed as a covered service. The Plan says the pontic is not listed as a covered service either.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 services are not among those covered under this benefit. Additionally, the Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart or listed with NC, then it is not covered.Therefore, we decided that the Plan does not have to pre-approve2 retainer crowns (D6752) and a pontic (D6242).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerebral perfusion analysis provided on March 13, 2020 billed with code 0042T.
You asked the Plan to pay for the cerebral perfusion analysis. You say that this was medically necessary and should be covered. The Plan denied your request. The Plan says this is excluded from coverage by the LCD.
The Plan must follow Medicare rules. Medicare rules say that services such as those described by 0042T will be denied as not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the cerebral perfusion analysis provided on March 13, 2020 billed with code 0042T.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Novafix skin substitute graft.
You asked the Plan to pre-approve a Novafix skin substitute graft. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the records received indicate that the enrollee does not have adequate blood flow to the area of the wound. The Plan says that 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 Novafix skin substitute graft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee's wound has very poor blood flow, which would not make him a good candidate for grafting. Capillary refill time was more than 3 seconds and foot pulses were absent. 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 Novafix skin substitute graft have not been met. Therefore, we decided that the Plan does not have to pre-approve a Novafix skin substitute graft.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist visit provided on June 24, 2020.You asked the Plan to waive the copayment forthe specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $40 copayment for each Medicare-covered visit with a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a specialist visit on June 24, 2020. You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 specialist visit provided on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by an out-of-network provider on October 2, 2019.You asked the Planto waive the coinsurance for an outpatient surgery. You say that you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct coinsurance 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 40% coinsurance for outpatient surgery/out-of-network. You have been asked to pay a 40% coinsurance of the allowed amount for an outpatient surgery provided by an out-of-network provider. The total allowed amount is $229.64. The total amount you are being asked to pay is $91.86. At the time of this surgery you had only paid $6,946.76 of your $10,000 combined in-network and out-of-network limit. An outpatient surgery falls within the outpatient surgery/out-of-network 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 an outpatient surgery provided by an out-of-network provider on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic mammography (77065) and diagnostic digital tomosynthesis (G0279) provided on August 13, 2020.You asked the Plan to pay forCPT codes 77065 and G0279. 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.In this case, there were no medical records provided confirming that two separate diagnostic mammography's (77065) and diagnostic digital tomosynthesis (G0279) were given. The medicalrecords provided are duplicates of one another, indicating that only one diagnostic mammography (77065) and diagnostic digital tomosynthesis (G0279) were provided on August 13, 2020.Therefore, we decided that the Plan does not have to pay forthe diagnostic mammography (77065) and diagnostic digital tomosynthesis (G0279) provided on August 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on March 9, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the records provided do not support the services 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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pay for this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided do not have sufficient documentation to validate aninjection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch was performed. 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 pay forphysician services provided to the enrollee on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that youwould benefit from care in an IRF in order to gain strength and receive chemotherapy treatment.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's care can be provided safely at a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewersays that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is notshown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says a SNF admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when thefour factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy and occupational therapy in the SNF. The enrollee was at a stand-by assist to contact-guard assist level with functional mobility, including gait to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs or skilled therapy service 
needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bite wing x-rays (D0274) and the resin based composite (D2394) provided.

You asked the Plan to pay for the dental services. You say that the services you received were denied as medical. You also say that the services you received were dental services.The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that the bite wing x-rays are not listed as a covered dental service. The Plan says the resin based composite is not listed as a covered dental service either.

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 dental services that you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the bite wing x-rays (D0274) and the resin based composite (D2394) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided by a participating provider on March 17, 2020.You asked the Planto waive the copayment for urgently needed services. You say that you do not agree with this copayment. 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 $30 copayment for urgently needed services/contracted. You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services falls within the urgently needed services/contracted 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 urgently needed services provided by a participatingprovider on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 26, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an office visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $10 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you had an office visit with your primary care physician on February 26, 2020. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician/Practitioner 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 the office visit provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on December 19, 2018.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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 forphysician services provided to the enrollee on December 19, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for tuberculosis screening provided to the enrollee on March 5, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this type of screening is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. This testing 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 tuberculosis screening provided to the enrollee on March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laminectomy services provided on July 15, 2019.You asked the Plan to pay forthe laminectomy 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.The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. In this case, sufficient medical records were not provided for review in order to determine if the services at issue were billed correctly based on Medicare criteria.Therefore, we decided that the Plan does not have to pay forthe laminectomy services provided on July 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (PCD).You asked the Plan to pre-approvethese 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. Medicare rules say that a PCD for the prevention of venous thromboembolism is non-covered.We looked at the file and Medicare rules. The file shows that the PCD is being requested for prevention of venous thromboembolism. Medicare does not cover this item for this purpose.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (PCD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.

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 self-administered drugs are not covered.

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 Otezla.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOxybutynin.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says self-administered drugs are not covered.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-approveOxybutynin.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights