Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mouth and jaw surgery, a screw placed in your bone to hold a false tooth (crown or denture), bone grafts, mouth appliances and x-rays (21030, 21040, 21079, 21085, 21210, 21215, 41874, 70355, D6010).You asked the Plan to pre-approve mouth and jaw surgery, a screw placed in your bone to hold a false tooth (crown or denture), bone grafts, mouth appliances and x-rays. 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. 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 mouth and jaw surgery, a screw placed in your bone to hold a false tooth (crown or denture), bone grafts, mouth appliances and x-rays. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested treatment essentially aims to remove infections that are dentally based, and to restore the damaged supporting bone with grafting and then replace the missing teeth. The proposed treatment is not secondary to a medical procedure that could be a covered service. This treatment is clearly beyond the scope of Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mouth and jaw surgery, a screw placed in your bone to hold a false tooth (crown or denture), bone grafts, mouth appliances and x-rays have not been met.Therefore, we decided that the Plan does not have to pre-approve mouth and jaw surgery, a screw placed in your bone to hold a false tooth (crown or denture), bone grafts, mouth appliances and x-rays (21030, 21040, 21079, 21085, 21210, 21215, 41874, 70355, D6010).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits and 3 home health
physical therapy (PT) visits.
You asked the Plan to pre-approve 3 home health skilled nursing visits and 3 home health PT visits. You say
that the services are necessary. The Plan denied your request. The Plan says based on the documentation,
coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 3 home health skilled nursing visits and
3 home health PT visits. Our reviewer says that the services are not medically necessary. Our physician
reviewer found based on the medical records provided the records do not show that skilled therapy services are
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or
prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 3 home health skilled nursing visits and 3 home health PT visits have not been
met. Therefore, we decided that the Plan does not have to pre-approve 3 home health skilled nursing visits and
3 home health physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ECG, cardiology services, and supplies provided on January 30, 2020.
You asked the Plan to pay for the ambulance ECG, cardiology services, and disposable supplies. You say that the service was medically necessary. The Plan denied your request. The Plan says ambulance services and supplies are not separately payable.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The services and supplies are included in the Medicare ambulance pay rate. Based on this information, we decided that Medicare rules for coverage of ambulance ECG, disposable supplies, have not been met. Therefore, we decided that the Plan does not have to pay separately for the ECG, cardiology services and supplies provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 lab services provided on December 11, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy and injections provided by a participating provider on March 6, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy and injections. You say that this was supposed to be a screening. 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). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient hospital services/in-network and a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a $225 copayment for a diagnostic colonoscopy and a 20% coinsurance of the allowed amount for injections. The total allowed is $225.76. The total coinsurance amount you are being asked to pay is $54.16 ($225.76 x 20% = $45.16). The total amount you are being asked to pay is $270.16 ($225 + $45.16 = $270.16). A diagnostic colonoscopy falls within the outpatient hospital services/in-network and injections falls within the Medicare Part B prescription drugs/in-network 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 a diagnostic colonoscopy and injections provided by a participating provider on March 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve blocks.You asked the Plan to pre-approve nerve blocks. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 nerve blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the effectiveness of Genicular nerve blocks to treat pain due to osteoarthritis of the knee has not been established. As such, Genicular nerve blocks utilizing iovera Cryoanalgesia are not 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 nerve blocks have not been met.Therefore, we decided that the Plan does not have to pre-approve nerve blocks
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (95885, 95955, 95909) provided on May 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed codes are 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 95885 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition tocode for primary procedure)". The CPT Code Manual definition of code 95955 is "Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)". The CPT Code Manual definition of code 95909 is "Nerve conduction studies; 5-6 studies".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 services. Our reviewer says that the use of CPT codes 95885, 95955, and 95909 is not supported by the records provided. Our physician reviewer found that the technical report in the case file does not include documentation of a limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity studies. The documentation supports that real time EEG monitoring was done, which is not covered by code 95955. The documentation does not include measurements of amplitude, latency, and conduction velocity. As a result, code is 95909 substantiated by the clinical documentation in the technical report submitted for review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (95885, 95955, 95909) provided on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 3, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 pay for the drug testing services provided on October 3, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the drug testing. We decided that the Plan does not have to pay for the definitive drug testing. You asked the Plan to pay for the drug testing. You say that this testing is medically necessary and should be covered. The Plan says that there is no valid order for this testing. We decided that the Plan has to pay for the presumptive drug testing.
The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating practitioner. In this case, the file contains an electronically signed order which clearly indicates that a presumptive screening is requested. Therefore, we decided that the Plan has to pay for the drug testing. We also decided that the Plan does not have to pay for the definitive drug testing. The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating practitioner. The submitted order form does indicate a request for a definitive drug test but it is not clear that this request is for a full panel or for the provider's custom panel. Without this documentation, it cannot be confirmed the intent for the testing provided. Therefore, we decided that the Plan does not have to pay for the definitive drug testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair seat cushion (E2606).You asked the Plan to pre-approve the cushion. You say that the cushion 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 a wheelchair cushion may be covered when an enrollee with a covered wheelchair has any significant postural asymmetries due to a condition listed in the Policy Article.We looked at the file and Medicare rules. The record does not show the enrollee has a condition that is eligible for coverage of the seat cushion. Based on this information, we decided that Medicare rules for coverage of the cushion have not been met.Therefore, we decided that the Plan does not have to pre-approve a wheelchair seat cushion (E2606).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on March 25, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the CT scan copayment because that was not the original test your doctor ordered. The Plan denied your request. The Plan says you have been charged 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 $275 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the CT scan.
You have been asked to pay a $175.55 copayment for the CT scan. The CT scan 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 CT scan provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no evidence that you are currently able to fully participate in at least three hours of rehab daily, for at least five days a week.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. While you may benefit and participate in multiple therapies, your functional level does not requires this or can tolerate this therapy on an intensive rehabilitation therapy program provided in an IRF.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe medical nutrition therapy services. You say that you would like reconsideration because the medical nutrition therapy services are medically necessary.The Plan denied your request. The Plan says the member will require a long-term nutritional support to meet their needs however, they should consider an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial denture (D5213).
You asked the Plan to pre-approve the dental services. You say that your partial was lost due to an accident.
You really need it to help you eat and chew your food. The Plan denied your request. The Plan says this request
exceeds the benefit frequency limitation.
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. This service is covered once
every 5 years. The records show that you received this service July 25, 2019.
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
upper partial denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCryamza.You asked the Plan to pre-approveCryamza. The Plan denied your request. The Plan says the enrollee does not meet medically-accepted standards.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 Cryamza. Our physician reviewer found that the request is for Cryamza for the treatment of hepatocellular cancer. Per criteria, requirements include subsequent treatment as a single agent for progressive disease in patients who have unresectable disease, are not a transplant candidate, are inoperable by performance status or comorbidity, or have local disease or local disease with minimal extrahepatic disease only have metastatic disease or extensive liver tumor burden. The drug requires the enrollee to have alpha feta protein greater than or equal to 400ng/mL. There is no provided documentation with information meeting these standards. The review has determined thatthe documentation does not support that Cryamza is medically reasonable and necessary for the enrollee. The documentation does not support that Cryamza is safe and effective 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 Cryamza have not been met.Therefore, we decided that the Plan does not have to pre-approveCryamza.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (CPT 95937) provided to the enrollee on November 14, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says procedure code 95937-26 is not supported by the medical records submitted.
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 95937 is "neuromuscular junction testing (repetitive stimulation, paired stimuli), per each nerve, by any 1 method." 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 testing. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the intraoperative neurophysiology report did not include documentation of neuromuscular junction testing (repetitive stimulation, paired stimuli), per each nerve, by any 1 method. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (CPT 95937) provided to the enrollee on November 14, 2019.