Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided by a participating hospital on November 23, 2020.
You asked the Plan to waive the copayment for outpatient mental health services. You say that this was all part of a treatment plan. You say that this should be covered 100%. The Plan denied your request. The Plan says the correct copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for outpatient mental health care/outpatient hospital. The enrollee has been asked to pay a $120 copayment for outpatient mental health services. The correct copayment has been applied to the services that were provided. Outpatient mental health services fall within the outpatient mental health care/outpatient hospital benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient mental health services provided by a participating hospital on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2750).
You asked the Plan to pre-approve a crown. You say that you cannot afford this service. The Plan denied your request. The Plan says crowns are 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 pre-approve a porcelain/ceramic crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 21, 2020.
You asked the Plan to pay for the office visit. You say that you are resubmitting the claim with documentation to support the charges. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided by an out-of-network provider on December 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the drainage of fluid from abdominal cavity using imaging guidance provided on October 21, 2020.
You asked the Plan to pay for the drainage of fluid from abdominal cavity. You say that you would like to appeal this service. The Plan denied your request. The Plan says the Plan spoke with the provider on February 23, 2021 and confirmed that they have submitted the bill to Traditional Medicare for payment. The Plan also confirmed that the enrollee's family is not being billed for these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the drainage of fluid from abdominal cavity using imaging guidance provided on October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumber (L2-L5) fusion with neuromonitoring.
You asked the Plan to pre-approve lumber (L2-L5) fusion with neuromonitoring. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 lumber (L2-L5) fusion with neuromonitoring. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for multilevel lumbar fusion is not met. There is no instability or very severe deformity documented. Multilevel fusion for degenerative back pain has poor results documented in the literature. Since the surgery is not needed than the monitoring is also not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumber (L2-L5) fusion with neuromonitoring have not been met. Therefore, we decided that the Plan does not have to pre-approve lumber (L2-L5) fusion with neuromonitoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 5, 2020.
You asked the Plan to pay for the orthosis. You say that please review and process the claim for payment as the enrollee is using the brace and it is helping with her problems. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record only documents subjective findings and does not provide objective evidence sufficient to satisfy the elements of the coverage criteria. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic biometry services coded 92136 provided on November 20, 2020.
You asked the Plan to pay for the ophthalmic biometry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 92136 is ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. We find that CPT code 92136 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. Based on this information, we decided that Medicare rules for coverage of the ophthalmic biometry services have not been met. Therefore, we decided that the Plan does not have to pay for the ophthalmic biometry services coded 92136 provided on November 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 in the Medicare rules section 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 the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does 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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Rituxan.
You asked the Plan to pre-approve Rituxan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Rituxan is correct, because this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Rituxan. Our reviewer says that the enrollee meets the Medicare criteria for use of Rituxan. Our physician reviewer found the requested use of Rituxan is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Rituxan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health admission.
You asked the Plan to pre-approve inpatient mental health admission. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, the admission of this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. The enrollee was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. The enrollee was not exhibiting withdrawal symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health admission.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to hold you harmless for the ultrasound services received on September 9, 2020 minus any cost share requirement.
You asked the Plan to hold you harmless for the ultrasound services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services received are not medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You received the ultrasound services by a contract provider. The file does not show that the Plan provided notice that the ultrasound services would not be covered. Under Medicare rules, this means the ultrasound services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the ultrasound services received on September 9, 2020 minus any cost share requirement.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Wats3D biopsy (88313).
You asked the Plan to pay for a Wats3D biopsy. You say that this should be covered. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a Wats3D biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found published guidelines indicate that the quality of the evidence supporting the Wats3D biopsy is low and the use of the Wats3D biopsy is only endorsed as a conditional recommendation. 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 Wats3D biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a Wats3D biopsy (88313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320), a porcelain/ceramic pontic (D6245), two porcelain/ceramic retainer crowns (D6740) and two core buildup procedures (D2950).
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 these services are 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 pre-approve endodontic therapy (D3320), a porcelain/ceramic pontic (D6245), two porcelain/ceramic retainer crowns (D6740) and two core buildup procedures (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the partial mandibular denture (D5214).
You asked the Plan to pay an additional amount for the partial mandibular denture. You say that you would not have gotten this item if you knew it was going to be so expensive. The Plan denied your request. The Plan says the correct cost share applied to this claim.
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. You have been asked to pay a 70% coinsurance for the partial denture (70% of $1686.00 = $1,180.20). 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 pay an additional amount for the partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310).
You asked the Plan to pre-approve endodontic therapy. You say that this service is medically necessary, and you cannot afford it. The Plan denied your request. The Plan says endodontic services are 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 pre-approve endodontic therapy (D3310).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
You asked the Plan to pre-approve 5 additional physical therapy visits. You say that the patient appears to have improved with therapy to the point of being able to manage basic activities of daily living and yard work including planting trees. Transition to a home exercise program appears appropriate at this point. The Plan denied your request. The Plan says the enrollee's needs can be met with a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 5 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient appears to have improved with therapy to the point of being able to manage basic activities of daily living and yard work. Transition to a home exercise program appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement porcelain/ceramic crown (D2740) and core buildup procedure (D2950) for tooth #5.
You asked the Plan to pre-approve the replacement crown and core buildup. You say that it is necessary to have this crown replaced. There is an open margin with no contact. The Plan denied your request. The Plan says the x-rays provided do not show any reason for a replacement crown.
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. The Plan covers the replacement crown and core buildup when the services are medically necessary and reasonable. 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 replacement crown and core buildup. Our reviewer says that it cannot be determined that the services are medically necessary based on the provided records. Our physician reviewer found that the provided x-rays show a crown on the requested tooth that has an open space on the mesial aspect (diastema), but it is not clear that this was not a reproduction of a normal space that was there prior to the initial crown placement and simply reproduced with the prosthesis. A diastema is commonly naturally occurring and does not pose any issue unless food is being impacted between the teeth, which is an issue that was not addressed in the records. The note of an open margin is not definitive for the need to replace a crown; a decaying open margin would be of concern but there are many crowns with several years of service that have small open margins that do not decay and would not be a reason to replace a crown. There is no mention of loss of function of the tooth and no decay described in the margin. There is nothing to indicate the crown is no longer serviceable in the record.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the replacement crown and core buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement porcelain/ceramic crown (D2740) and core buildup procedure (D2950) for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of reaction producing foreign bodies (D7540).
You asked the Plan to pre-approve removal of reaction producing foreign bodies. You say that this service is medically necessary, and you cannot afford this procedure without insurance. 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 pre-approve removal of reaction producing foreign bodies (D7540).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by a chiropractor.
You asked the Plan to pre-approve an office visit to be provided by a chiropractor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve an office visit to be provided by a chiropractor.