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

We decided that the Plan does not have to pre-approve insertion of a wireless pulmonary artery pressure sensor (CardioMEMS procedure).
You asked the Plan to pre-approve CardioMEMS procedure. You say that by implanting this device it will allow monitoring the enrollee remotely, alleviating the need for frequent procedure and testing and can prevent future heart failure admissions. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not covered by Medicare.
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 CardioMEMS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data from a CardioMEMS device has been demonstrated in only 1 trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. This procedure should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a wireless pulmonary artery pressure sensor (CardioMEMS procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on October 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on October 4, 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS. We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 assistant surgeon services rendered on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the typhoid vaccine rendered on March 5, 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.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the typhoid vaccine rendered on March 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee. You asked the Plan to pre-approve the syringe. You say that this is is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed. 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 the syringe. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that Zoledronic acid has been tried and failed. The documentation does not support that Zoledronic acid 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 the syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 16, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says that 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 nurse practitioner services provided on December 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99284) provided on December 2, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this member was seen multiple times on the same date of service. The Plan denied your request. The Plan says the member's claims history indicates that CPT code 99284 was already allowed for this date of service and there is no other information on the denied claim which would indicate these services were unrelated.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We find that CPT code 99284 is not supported in the record. Specifically, the record indicates that this service was already rendered and allowed for this date of service. The claim does not include a modifier to show that these services were unrelated. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99284) provided on December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a tissue exam (88305 26) provided on October 17, 2019.
You asked the Plan to pay for the tissue exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to report a procedure both as a global service and as a technical or professional component.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 88305 26 is not supported in the record. Specifically, the record indicates that CPT code 88305 was billed globally and paid for the same date of service. Because the global service has been paid, billing of the professional or technical component is inappropriate. Based on this information, we decided that Medicare rules for coverage of the tissue exam have not been met. Therefore, we decided that the Plan does not have to pay for a tissue exam (88305 26) provided on October 17, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to provide Avastin. You asked the Plan to provide Avastin (J9035). You say that the enrollee meets the requirement for this drug. The Plan denied your request. The Plan says that the enrollee does not have a qualifying eye problem. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide Avastin (J9035). Our reviewer says that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found this appeal considers the medical necessity of Avastin for the treatment of bilateral proliferative retinopathy and macular edema. Submitted documentation, Medicare guidelines, and Medicare approved compendia were considered. The enrollee has a diagnosis of type 2 diabetes mellitus. Review of compendia supports the use of the requested medication for the treatment of macular edema in people with diabetes. Medical necessity is determined. The denial is overturned. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avastin (J9035) have been met. Therefore, we decided that the Plan has to provide Avastin.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on October 11, 2019.You asked the Plan to reduce the copayment for the office visit. You say that you weren't informed that the provider is contracted as a specialist. You say that the copayment should be $10.The Plan denied your request. The Plan says that the $50 copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for each in-network, Medicare-covered PCP visit. The Plan says you must pay a $50 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the office visit. The records show that the office visit was provided by a nurse practitioner at a primary care office. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on October 11, 2019.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 medical services provided on October 30, 2019 by an out of network (OON) provider.
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 were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tdap vaccine.You asked the Plan to pre-approve the vaccine. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pre-approve Tdap vaccine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cone beam CT imaging (D0364) provided on October 31, 2019.
You asked the Plan to reimburse you for the dental service. You say that you paid for the dental service upfront due to the provider being out of network. You say that you were advised you would be reimbursed once insurance went through. You also say that you have been given conflicting information as to whether the service was dental or medical in nature. The Plan denied your request. The Plan says the service that you received is dental in nature. The Plan also says cone beam CT imaging is not 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 cone beam CT imaging is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the cone beam CT imaging (D0364) provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on August 18, 2019.You asked the Plan to pay for the testing. You say that this should be paid for.The Plan denied your request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for this testing.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 testing have not been met.Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on August 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia for impacted tooth removal. You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. 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 pre-approve deep sedation/general anesthesia for impacted tooth removal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 27, 2020.
You asked the Plan to waive the copayment for an office visit. You say that this was you annual wellness visit and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $25 copayment for each visit to a primary care physician. The medical records show that you received services beyond an annual wellness visit on January 27, 2020. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injections provided on May 2, 2019 to November 4, 2019. You asked the Plan to reduce the coinsurance for the Part B injections. You say that you should only be charged $11.65 for the Prolia injections. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance. for all other drugs covered under Medicare Part B. You have been asked to pay a total of $462.32 for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" 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 reduce the coinsurance for the Part B injections provided on May 2, 2019 to November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe autogenous connective tissue graft procedure (D4273) provided on October 15, 2019.You asked the Plan to reimburse you forthe dental service. You say that surgical procedures are covered by Medicare. You also say that you were advised by a plan representative that advised your portion of the procedure would be $295.The Plan denied your request. The Plan says the service you received was dental in nature. The Plan says you are not enrolled in the supplemental dental plan. The Plan also says that the autogenous connective tissue graft procedureis not a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the record shows that the Plan was not able to locate any calls made to them regarding the service that you received.Therefore, we decided that the Plan does not have to reimburse you forthe autogenous connective tissue graft procedure (D4273) provided on October 15, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 6, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 subsequent nursing facility care provided on January 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from August 13, 2019 to August 16, 2019.
You asked the Plan to pay for the dental service. You say that there was not an oral surgeon in your area. The Plan denied your request. The Plan says these services were provided by a dentist that is not in the Plan's network. The Plan also says that your contract does not cover services that are provided by vendors outside of the Plan's 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 the dental services provided from August 13, 2019 to August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D photographic image (D0351) provided December 16,
2019.
You asked the Plan to pay for the dental services. You say that it seems logical for the plan to pay at least a
minimum portion of the claim to replace the bone and to regenerate the guided tissue. The x-ray was necessary
to check on the healing progress. The Plan denied your request. The Plan says this service is not covered under
the plan benefits.
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 3D
photographic image (D0351) provided December 16, 2019.