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

We decided that the Plandoes not haveto pre-approvea home ventilator.You asked the Planto pre-approvethe ventilator. You say that there is currently nothing to help with breathing.The Plandenied your request. The Plansaysthere is no documentation of a failed trial of BiPAP when you were medically stable.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have severe COPD, and were recently admitted with a COPD exacerbation, acute hypercarbic respiratory failure, a cardiac arrhythmia, and acute myocardial infarction with left ventricular failure. You required intubation. A home ventilator was prescribed at discharge. There is no evidence that BiPAP has been tried and failed while the patient was in a stable state. Medicare does not cover home ventilators when used as BiPAP devices. Certain BiPAP devices are capable of providing the AVAPS-AE mode of ventilation. You would likely qualify for coverage of BiPAP, but a home ventilator is considerednot 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 ventilator have not been met.Therefore, we decided that the Plandoes not haveto pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 periodontal scalings and root planings provided on August 8, 2019.
You asked the Plan to pay for the scalings and planings. You say that you find it odd that you were charged the same amount to clean 1 tooth as you were charged to clean 3 teeth. The Plan denied your request. The Plan says this procedure is not a benefit under the dental plan.
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 2 periodontal scalings and root planings provided on August 8, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on November 1, 2018.You asked the Plan to waive the copayment forthe ED visit. You say that you went to the ER for an MRI but did not get one. You say that you disagree with the copayment.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 $100 for each visit to an emergency room.You have been asked to pay a $100 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the emergency department. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe ED visit provided on November 1, 2018.Your complaint about substandard care is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services (G0483) provided on July 11, 2019.You asked the Plan topay forthe laboratory services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed priorto services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services (G0483) provided on July 11, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 22, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you never got charged for these services before. You say that you should not be responsible now. 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 $20 for Medicare-covered laboratory tests. You have been asked to pay $20 for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services rendered to you by Julie Baar, ACNP on August 26, 2019.
You asked the Plan to waive the deductible for these services. You say that you assumed the services were for a free annual physical exam. The Plan denied your request. The Plan says the deductible was 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 there is $325 yearly deductible for your covered in-network medical services. The item or service you asked the Plan to waive the deductible for falls within the Medicare-covered visit with a specialist benefit category. The services fall outside of the scope of an annual physical exam. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $325 yearly deductible for your covered in-network medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on August 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the services rendered to you by Julie Baar, ACNP on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on August 14, 2019.
You asked the Plan to pay for the compression stockings. You say that you require these stockings and will require them your whole life. You had a blood clot in 1976 and require these to prevent another one. The Plan denied your request. The Plan says the rules say that elastic stockings are generally not covered because they considered non-reusable items that do not meet the definition of durable medical equipment.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered 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 pay for the compression stockings identified with code A6530 that were issued on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a latera implant.You asked the Plan to pre-approvea latera implant. The Plan denied your request. The Plan says this is not medically reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a latera implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that several studies have established that the Latera implant is safe and efficacious with minimal complications. It is a minimally invasive way to treat nasal valve collapse. The alternative is to perform surgery and use cartilage grafts or nonabsorbable implants to support the nasal sidewall. The evidence supporting the use of the Latera implant is industry sponsored. The published articles do not include a control arm with patients who were treated with standard surgical procedure. Therefore, there is no evidence that the Latera implant is superior to surgical treatment methods. The Latera implant is considered experimental and 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 a latera implant have not been met.Therefore, we decided that the Plan does not have to pre-approvea latera implant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by out of network 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-participating 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 August 6, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery provided on June 19, 2019.
You asked the Plan to pay for the osseous surgery. You say that you went to this provider to have laser surgery to remove/close a pocket on the right upper side of your mouth near your bridge. You also say that you do not feel that this provider did the job correctly and now you have to go to another provider to have the issue resolved before it ruins your partial dentures. The Plan denied your request. The Plan says you have reached your yearly dental benefit of $300. The Plan also says that you were appropriately billed the remaining $1,067 for the amount that was not covered by your plan.
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 Plan offers a $300 annual dental benefit maximum. The contract says that you are responsible for 100% of all charges that exceed the maximum allowable benefit per service, any dental services not covered under this benefit, or once the $300 annual benefit amount is reached. The record shows that you met the annual deductible benefit on June 19, 2019 and your annual deductible benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the osseous surgery provided on June 19, 2019.
Your complaint about this provider not doing his job of fixing the pocket in your tooth is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Procrit (J0885).

You asked the Plan to pre-approve this medication. You say that the use of Procrit is medically necessary due to iron deficiency anemia from blood loss. The Plan denied your request. The Plan says the requested drug is subject to step therapy. This requirement encourages the patient to try the preferred drug Retacrit, which is just as effective. If the preferred drug is utilized, it will be covered. The Plan says they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.

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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the medication Procrit. Our physician reviewer found that the patient has not tried and failed the required drug Retacrit. Retacrit is a biosimilar to Procrit and it is as safe and 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 this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the medication Procrit (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95913) and needle electromyography (95886) provided on March 12, 2019.
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not support the billed services.
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 95913 is nerve conduction studies; 13 or more studies. We asked our coder 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 nerve conduction studies and needle electromyography. Our reviewer says that CPT code 95913 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation that a Nerve conduction study of 13 or more studies was performed Our reviewer found CPT Code 95886 does not meet criteria for billing or reimbursement consideration. CPT code 95886 is an add-on code and requires the associated primary code to be eligible for reimbursement. In this case, the primary CPT code 95913 is not eligible for reimbursement, thus, making CPT 95886 ineligible for reimbursement as well.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forrepair of hearing aids provided on September 27, 2019.You asked the Plan to reimburse you forthe repair of hearing aids.The Plan denied your request. The Plan says hearing aid repairs are not covered services.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 inthis case. We looked at the file and the Plan's rules. The file shows that hearing aid repairs are not covered services. Therefore, we decided that the Plan does not have to reimburse you forrepair of hearing aids provided on September 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says 2 visits are approved to update your progress.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 12 physical therapy visits were requested. The plan has agreed to pre-approve 2 visits. 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 additional services. Our physician reviewer found that the documentation does not indicate the requested therapy is generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration beyond what was already approved by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron HCL, 25 mcg.
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 services were not considered medically necessary.
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 drug is not medically reasonable or necessary. Our physician reviewer found there are no medical records provided. Unfortunately, without medical records an indication for the use of palonsetron cannot be extracted. Palonsetron is indicated for the the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses in patients treated with moderately emetogenic cancer chemotherapy in adults; prevention of acute nausea and vomiting associated with initial and repeat courses in patients treated with highly emetogenic cancer chemotherapy in adults and for postoperative nausea and vomiting. The service is not reasonable or medically necessary and safe and effective use cannot be determined. 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 Palonosetron HCL, 25 mcg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.
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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary in this case. The provided medical records do not indicate that you have tried and failed the Plan's required drugs or that they would likely be less effective and/or likely have adverse effects. Our physician reviewer found that your condition does not meet criteria for coverage of Synvisc-Onc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the out-of-network coinsurance fora screening mammogram (77063, 77067) provided on August 5, 2019.You asked the Plan to waive the out-of-network coinsurance forthe mammogram. You say that the coinsurance should be waived for this annual screening.The Plan denied your request. The Plan says the EOC clearly explains a coinsurance is applied when screening mammograms are received out-of-network.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 50% coinsurance for Breast Cancer Screenings when they are rendered by out-of-network providers. You have been asked to pay a 50% coinsurance for the mammogram provided by an out-of-network provider. The mammogram falls within the Breast Cancer Screenings 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 out-of-network coinsurance fora screening mammogram (77063, 77067) provided on August 5, 2019.