Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of the sacroiliac (SI) joint.
You asked the Plan to pre-approve the SI joint injection. You say that it is felt that the requested injection is
needed. The Plan denied your request. The Plan says there are not at least three positive tests for SI joint pain.
As such, this treatment is not supported at this time.
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 SI joint injection. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has chronic low back pain. He has tenderness over the SI joint and a positive Faber
test on the contra-lateral side. There is no imaging of the SI joint submitted. There is no documentation of other
physical exam findings to support the SI diagnosis. Without additional testing showing that the SI joint is the
source of the pain, this injection is not considered 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 the SI joint injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an injection of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids you received on June 11, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says this is not a
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids you
received on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onabotulinumtoxina (Botox).

You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the drug is not being prescribed for a medically-accepted indication. The Plan also says that the enrollee does not have a compendia supported indication.

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 pre-approve Botox. Our reviewer says that Botox is not medically reasonable and necessary for the enrollee. Our physician reviewer found Botox is not Food and Drug Administration (FDA) approved for use in the management of acquired neuromyotonia. Our reviewer also found that the use of Botox for acquired neuromyotonia is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Onabotulinumtoxina (Botox).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea PET scan.You asked the Plan to pre-approvea PET scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the documentation does support that the requested PET scan is medically reasonable and necessary.Our physician reviewer found the enrollee stage III non-small cell lung cancer and is status post definitive treatment. A CT scan of the chest shows density right hilum and subjacent pleura right perihilar consolidation. A PET scan is recommended by the enrollee's radiologist. The documentation shows that the requested PET scan meets criteria as it is strongly suspected recurrence. Therefore, the enrollee meets criteria for the requested PET scan.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 PET scan have been met.Therefore, we decided that the Plan has to pre-approvea PET scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on August 6, 2020, by an out-of-network provider.You asked the Plan to waive the copayment forthe ambulance transport. You say that the ambulance claim was processed as out-of-network. You state you were transferred due to an emergency and had no time to look for an in-network emergency transport.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the ambulance transport on August 6, 2020, by an out-of-network provider. You were asked to pay a $265 copayment for the ambulance services. The cost-sharing is the same whether you use an in-network or out-of-network ambulance provider. Your 2020 EOC states that enrollees must pay a $265 copayment for each in-network or out-of-network Medicare-covered one-way trip via ground ambulance. 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 nothave to waive the copayment forthe ambulance transport provided on August 6, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction you had on September 2, 2020.You asked the Plan to pay forthe refraction. 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 these services when provided during a routine exam performed by an EyeQuest Routine Vision Care Provider.We looked at the file and the Plan's rules. The requested refraction was not provided as part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met.Therefore, we decided that the Plan does not have to pay forthe eye refraction you had on September 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the services provided on May 19, 2020, and June 16, 2020, by an in-network provider.
You asked the Plan to waive the cost-sharing for the services. You say that you have received numerous bills from this provider with inflated costs for your intravenous infusions. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the services on May 19, 2020, and June 16, 2020, by an in-network provider. The provider billed procedure code 96365 in the amount of $743.00. The allowed amount for procedure code 96365 is $175.05. Since the allowed amount is less than the outpatient hospital service benefit's copayment of $275.00, the plan applied a lesser amount of $175.05 as the member's copayment.
The provider billed procedure code 96366 in the amount of $144.00. The allowed amount for procedure code 96366 is $36.31. Since the allowed amount is less than the outpatient hospital service benefit's copayment of $275.00, the plan applied a lesser amount of $36.31 as the member's copayment. The provider billed procedure code 96375 in the amount of $175.00. The allowed amount for procedure code 96375 is $36.31. Since the allowed amount is less than the outpatient hospital service benefit's copayment of $275.00, the plan applied a lesser amount of $36.31 as the member's copayment. The provider billed provider code J1459 in the amount of $27,264.00. The allowed amount for procedure code J1459 is $3,297.36. The plan applied 20% to $3,297.36 for a coinsurance in the amount of $659.47. Together, the total cost share applied to the claim for date of service May 19, 2020 is $907.14 ($175.05 + $36.31 + $36.31 + $659.47 = $907.14). The plan applied the same cost shares to procedure codes 96365, 96366, 96375 and J1459 billed on the claim for date of service June 16, 2020. The total cost share applied to the claim for date of service June 16, 2020 is $907.14. The cost shares were correctly applied to the claims for dates of service May 19, 2020 and June 16, 2020. Your 2020 EOC states enrollees must pay 20% coinsurance for each Medicare-covered Part B drug obtained in-network and a $275 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 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 cost-sharing for the services provided on May 19, 2020, and June 16, 2020, by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml injections.
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your
request. The Plan says a trial of an injectable bisphosphonate such as zoledronic acid is required before
alternatives can be considered.
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 Prolia. Our reviewer says that Prolia is
not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug, or
any reason why the plan preferred drug would be unsafe or ineffective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia 60mg/ml injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe behavioral assessment rendered on January 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 96127 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 96127 is brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.We find that CPT code 96127 is not supported in the medical record. Specifically, there is no documentation of a brief emotional/behavioral assessment with scoring and 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 forthe behavioral assessment rendered on January 17, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
September 14, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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. When conducting a review of a
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary
and conducted a face-to-face assessment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was
performed. The information submitted does not confirm that Medicare coverage criteria have been met.
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the
enrollee on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on September 24, 2020.You asked the Plan to waive the coinsurance foran outpatient surgery. You say that you thought that since you stayed the night at the hospital you would be charged for an inpatient hospital stay. 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 20% coinsurance for outpatient surgery. You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $17,541.88. The total amount you are being asked to pay is $3,508.38 ($17,541.88 x 20% = $3,508.38. The correct coinsurance has been applied to the surgery that was provided. An outpatient surgery falls within the outpatient surgery 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 a participating provider on September 24, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic brachytherapy 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 research studies have found a lack of evidence that routine use of the requested
treatment would improve outcomes.
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 IORT with electronic brachytherapy is not within accepted standards of care. The guidelines recommend
against routine use of IORT with electronic brachytherapy.
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 electronic brachytherapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reduce the charges forthe periodic oral evaluation and prophylaxis. We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and prophylaxis. You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you feel these services should have been paid in accordance with the $10 copay. You also say that the provider told you that they were in-network with the Plan.The Plan says that these services were rendered by an OON provider, and the provider's network status was not verified prior to the services being rendered. The Plan also says that this claim has processed correctly.We decided that the Planhas to reduce the charges forthe periodic oral evaluation and prophylaxis. 
The rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.The EOC does not clearly explain that the 80% coinsurance amount would be applied to anything other than the billed charges. The enrollee did not know they would be responsible for more than the coinsurance amount when being seen by an OON provider.Therefore, we decided that the Plan has to reduce the charges forthe periodic oral evaluation and prophylaxis. We also decided that the Plandoes not have to waive the coinsurance for the periodic oral evaluation and prophylaxis.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, you must pay an 80% coinsurance for exams and cleanings that received OON.Therefore, we decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and prophylaxis.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 decideto open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient acute rehabilitation facility
(IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there are no ongoing critical care needs.
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 reviewer says 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 not shown 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 (ex. SNF/SAR).
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-approve admission to an inpatient acute rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transportation provided on July 30, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay forthe ambulance transportation provided on July 30, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an epidural injection.
You asked the Plan to pre-approve an epidural injection. You say that the requested epidural injection is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested epidural injection.
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 an epidural injection. Our reviewer says that the enrollee meets criteria for the requested epidural injection. Our physician reviewer found the enrollee has chronic low back pain which radiates into his leg. He has had 2 prior Epidural steroid injections, both of which provided greater than 50% pain relief for months. He has a recent MRI which shows disc bulges at two levels. The request is for repeat ESI. The request fully meets the criteria of the LCD. The request is medically reasonable and 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 an epidural injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural injection.