Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is considered a convenience item and not primarily medical in nature.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on October 28, 2020.
You asked the Plan to pay for the self-administered drug. You say that you needed urgent care. The Plan denied your request. The Plan says the medication does not qualify for reimbursement under your Part A and 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 drug provided on October 28, 2020.
Benefits for the self-administered 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on March 9, 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 procedure code 72197 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 72197 is magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences. We find that CPT code 72197 is not supported in the medical record. Specifically, there is no documentation of MRI of the pelvis without contrast material, followed by contrast materials for further sequences. 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 magnetic resonance imaging (MRI) rendered on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on December 2, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-intravenous conscious sedation (D9248) provided on October 1, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the non-intravenous conscious sedation (D9248) provided on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure provided on June 12, 2020.
You asked the Plan to pay for the arthroscopy, shoulder, surgical; repair of superior labrum anterior and posterior (SLAP) lesion (29807LT). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the operative report did not include documentation to meet the guidelines of a surgical shoulder arthroscopic repair of a SLAP lesion.
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 29807 is Arthroscopy, shoulder, surgical; repair of superior labrum anterior and posterior (SLAP) lesion (29807LT). 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 arthroscopy, shoulder, surgical; repair of superior labrum anterior and posterior (SLAP) lesion (29807LT). Our reviewer says that the procedure is not supported in the medical record. Our physician reviewer found the operative report does not properly document a SLAP repair. The code 2980LT cannot be justified based on the medical records. It should not be approved. 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 arthroscopy, shoulder, surgical; repair of superior labrum anterior and posterior (SLAP) lesion (29807LT) have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services received on October 15, 2020.
You asked the Plan to pay for the services. You say that you have never had a problem in the past for reimbursement. The Plan denied your request. The Plan says the rendering provider opted out of Medicare.
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 except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit services received on October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20 mg tablets.
You asked the Plan to pre-approve Xarelto. You say that this service is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the medical benefit.
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 Xarelto 20 mg tablets.
Benefits for Xarelto 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 waive the coinsurance for laboratory services provided on October 23, 2020.
You asked the Plan to waive the coinsurance for laboratory services. You say that you have never been charged in the past and 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 20% coinsurance for laboratory services. You received laboratory services on October 23, 2020. The allowed amount is $23.95 and 20% of that is $4.79. You have been asked to pay the total coinsurance amount of $4.79 for laboratory services. Laboratory services fall 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 coinsurance for laboratory services provided on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field examination (92083) provided on March 31, 2020.
You asked the Plan to waive the copayment for the visual field examination. You say that you would like reconsideration because there should not be a copayment for specialist services. The Plan denied your request. The Plan says there is a $40 copay per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk.
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 enrollees must pay a $40 copayment for Vision Care. You have been asked to pay a $40 copayment for the visual field examination. The visual examination falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visual field examination (92083) provided on March 31, 2020.b
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT image capture (D0382) and biological materials to aid in tissue regeneration with periradicular surgery (D3431) for tooth # 14.
You asked the Plan to pre-approve the dental services. You say that you have a piece of the root remaining and it is causing a problem in your gums after you had the first root canal service. You say that you are being referred to the Elmhurst location which has the equipment to do the service however you need to do CT scan imaging and biological implant that was denied. You say that you need it badly since it is affecting your gums and other teeth in your mouth. You also say that if this will take long you may end up in the emergency. The Plan denied your request. The Plan says cone beam CT image capture is not listed as a covered service. The Plan also says biological materials to aid in tissue regeneration with periradicular surgery 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT image capture (D0382) and biological materials to aid in tissue regeneration with periradicular surgery (D3431) for tooth # 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the allowance for your hearing aids purchased on June 12, 2020.
You asked the Plan to pay the allowance for hearing aids purchased from a non-preferred provider. You say that the listed network providers did not have anyone in/from your state within driving distance. The Plan denied your request. The Plan says you did not purchase the hearing aids through our hearing aid vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays a $500 allowance for hearing aids every 3 years, only when provided from the preferred provider. We looked at the file and the Plan's rules. You did not purchase from the Plan's designated provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay the allowance for your hearing aids purchased on June 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography for the enrollee.
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 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has underlying cardiac disease but had a recent echocardiogram done in October 2019 and her clinical status has been stable during that time. She has not had an intercurrrent ischemic event and she has no reported symptoms or signs of congestive heart failure on history or exam. There was no history of significant valvular heart disease on the 2019 as well. Repeat echocardiography here within approximately one year in the absence of clinical changes, recent MI or other clinical signs or symptoms of worsening congestive heart failure would not be medically indicated as part of the pre-operative assessment. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. there is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 6, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for this 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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the Plan contract states that two oral exams are covered every calendar year. The Plan previously issued payment for an oral exam provided on May 13, 2020 and August 6, 2020, less than one year prior. You have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for pulmonary perfusion imaging (78580) provided on July 7, 2020.
You asked the Plan to pay for the pulmonary perfusion imaging. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation supports 1(one) unit of 78580-26, which was previously approved/paid.
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 78580 is pulmonary perfusion imaging (eg, particulate). We find that CPT code 78580 is not supported in the record. Specifically, the record supports one unit of CPT code 78580 which was previously paid. There is no evidence in the documentation submitted to support an additional unit of this service. Based on this information, we decided that Medicare rules for coverage of the pulmonary perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pay for pulmonary perfusion imaging (78580) provided on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tab 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the medication is denied due to a benefit exclusion.
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 Eliquis tab 5mg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One 30mg/3ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational and not approved by the FDA.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the Food and Drug Administration (FDA) has approved GEL-ONE 30 MG/3 ML SYRINGE for the treatment of osteoarthritis of the knee. The enrollee's provider has requested an indication for use not approved by the FDA. Current studies and articles published in Medicare-approved literature do not show the treatment of osteoarthritis of the hip with GEL-ONE 30 MG/3 ML SYRINGE to be effective. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One 30mg/3ml syringe for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion (22612).
You asked the Plan to pre-approve lumbar spinal fusion. You say that you need this surgery because other treatments have not helped. The Plan denied your request. The Plan says the submitted records do not support this is 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 lumbar spinal fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent adequate trial of physical therapy, and there is no severe spinal stenosis shown in imaging. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion (22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-contact wound therapy and disposable supplies.
You asked the Plan to pre-approve non-contact wound therapy and disposable supplies. You say that these services are medically necessary. The Plan denied your request. The Plan says disposable supplies do not meet the definition of DME and the non-contact wound therapy is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that DME is covered when it meets certain requirements. The rules also say that non-contact wound therapy is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not provide coverage for non-contact wound therapy and disposable supplies. Therefore, we decided that the Plan does not have to pre-approve non-contact wound therapy and disposable supplies.