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

We decided that the Plan does not have to pre-approve a SmartVest Airway Clearance System.

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 enrollee does not have a diagnosis for which the services are covered.

The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.

The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to
pre-approve a SmartVest Airway Clearance System.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on October 26, 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 90847 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 90847 is family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes. 

We find that CPT code 90847 is not supported in the medical record. Specifically, the records show that the services were for an individual session and not family/group therapy. There is a more appropriate code for these services. 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 psychotherapy services rendered on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the echocardiogram provided on November 29, 2020, the nuclear stress test with radiotracer injection provided on December 1, 2020, the daily lab tests provided from November 29, 2020, through December 3, 2020, and the physical therapy services provided on December 2, 2020, and December 3, 2020.
You asked the Plan to waive the charges for the outpatient hospital services. You say that you do not believe that you should have to pay anything for this hospital stay. This cost should be absorbed fully by your Plan and Medicare. The Plan denied your request. The Plan says as the facility did not submit information to support the denial of the self-administered drugs, it was decided to make payment for these in the amount of $904.55. The remaining $307 was correctly applied as your cost sharing.
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 the cost sharing for medical services as described in the Medicare rules section. In this case, you have been asked to pay a $5 copayment for each of the daily lab tests you were provided during this hospital stay. In addition, you are asked to pay a $110 copayment for the echocardiogram, which is an ultrasound service, and the nuclear stress test, which is a specialized scan. The radiotracer that was injected by the nuclear stress tests was assessed 20% coinsurance as it is considered a Part B covered drug. You have also been asked to pay a $30 copayment for the two physical therapy sessions you were provided. 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 charges for the echocardiogram provided on November 29, 2020, the nuclear stress test with radiotracer injection provided on December 1, 2020, the daily lab tests provided from November 29, 2020, through December 3, 2020, and the physical therapy services provided on December 2, 2020, and December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Gel-One. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and
failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s)
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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6535.

You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6535 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6535.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a heavy duty commode chair.
You asked the Plan to provide a commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms (E0168). You say that you are too big for the commode chair you have. The Plan denied your request. The Plan says you do not meet the weight criteria.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file shows you do not weigh 300 pounds or more as defined by Medicare rules. Therefore, we decided that the Plan does not have to provide a heavy duty commode chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided January 28, 2021.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says at the time this claim processed, the enrollee had not met their deductible; therefore, the claim has processed 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 there is a $750 deductible for durable medical equipment. 

The item or service you asked the Plan to pay for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the therapeutic continuous glucose monitor was received on January 28, 2021. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999) provided on December 4, 2020.

You asked the Plan to pay for the unspecified preventative procedure. You say that your dentist told you that all services would be covered, and you would not have to pay anything. You cannot afford this charge. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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 pay for an unspecified preventative procedure (D1999) provided on December 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 11, 2020 to November 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that your original coverage should have been continued until the new policy took effect. The Plan denied your request. The Plan says you must receive your care from a network provider.

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 had network providers available who could have provided 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 lab services provided on November 11, 2020 to November 22, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided
December 4, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this
claim reconsidered for medical necessity. The Plan denied your request. The Plan says there was no evidence
of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. Although updated medical records were submitted, the
documentation does not corroborate the claim that the enrollee uses insulin with at least three daily injections.
Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose
monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic
continuous glucose monitor provided December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker evaluation services provided on September
10, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
service cannot be supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of code 93296 is interrogation device evaluation(s) (remote), up
to 90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable
defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical
support and distribution of results.
We find that CPT code 93296 is not supported. This is a technical component code. Payment for this service is
include in the facility payment. Based on this information, we decided that Medicare rules for coverage have
not been met. Therefore, we decided that the Plan does not have to pay for the pacemaker evaluation services
provided on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection procedure for discography, each level; lumbar (62290) and Discography, lumbar, radiological supervision and interpretation (72295).
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says these 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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has bilateral leg pain with numbness in the left great toe and weakness in the left L5 distribution. The enrollee is status post a multi-level laminectomy and a L5-S1 interbody fusion. The enrollee is taking Tramadol and Celebrex and has tried Gabapentin as well. Additionally, she has received physical and massage therapy. There is no indication for multi-level discography in this patient. The request is deemed not medically reasonable or 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 an injection procedure for discography, each level; lumbar (62290) and Discography, lumbar, radiological supervision and interpretation (72295).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you would like the 5 year frequency limitation waived because you need new dentures. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.

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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to once per 60 months. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on March 9, 2021 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on March 5,
2021.

You asked the Plan to waive the copayment for the ambulance ride. You say that you had to be transported to
another hospital. You say you had no choice but to take the ambulance. The Plan denied your request. The Plan
says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each separate Medicare-covered ambulance service.

You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance 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
ambulance ride provided on March 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on September 28, 2020.

You asked the Plan to waive the copayment for the MRI. You say that there is no copayment for services
through September. You say that you are on a fixed income and the money should be sent back. The Plan
denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $105 copayment for the MRI. The MRI falls within the "Outpatient Diagnostic
Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the MRI provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the
mandible or maxilla (D7950), removal of bone for graft (20900), injections of platelet rich plasma (0232T),
two guided tissue regenerations (D4266 x2), special service, procedure or report (99199), first 15 minutes of
deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general
anesthesia (D9223), therapeutic intravenous infusion (96365), inhalation of nitrous oxide/analgesia (D9230),
supplies and materials (99070), and extraction (D7140) provided on November 15, 2019.

You asked the Plan to pay for the osseous, osteoperiosteal, or cartilage graft, removal of bone for graft,
injections of platelet rich plasma, guided tissue regenerations, special service, procedure or report, deep
sedation/general anesthesia, therapeutic intravenous infusion, inhalation of nitrous oxide/analgesia, supplies
and materials, and extraction. You say that you would like these services to be covered under your medical
insurance. The Plan denied your request. The Plan says these services are not covered. The Plan also says that
the provider advised that you were informed these services would not be covered under medical.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay 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. You did not provide enough information to determine whether the services can be considered
eligible for Medicare coverage. Therefore, we decided that the Plan does not have to pay for the osseous,
osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), removal of bone for graft (20900),
injections of platelet rich plasma (0232T), two guided tissue regenerations (D4266 x2), special service,
procedure or report (99199), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15
minute increment of deep sedation/general anesthesia (D9223), therapeutic intravenous infusion (96365),
inhalation of nitrous oxide/analgesia (D9230), supplies and materials (99070), and extraction (D7140) provided
on November 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you have no other means of transportation. The Plan denied your request. The Plan says you have used 24 one-way transportation trips for this calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up to 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) and gingival irrigation (D4921).
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that gingival irrigation 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 periodontal maintenance (D4910) and gingival irrigation (D4921).