Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve outpatient Vocal Feminization Surgery, unlisted procedure, larynx.

You asked the Plan to pre-approve Vocal Feminization Surgery, Unlisted procedure, larynx (31599). You say that you need this procedure. The Plan denied your request. The Plan says that this surgery is listed as an exclusion on the Plan's medical policy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vocal Feminization Surgery, unlisted procedure, larynx (31599). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Voice feminization, not just pitch increase, is a very complicated and complexity modulation procedure. It is a comprehensive medical process in which all knowledge of speech science including laryngology, speech language pathology and acoustics must be applied. Voice feminization is a long transition journey that changes a male phonatory system including phonatory organs and pattern to a female phonatory system. From the patient's perspective, treatment modality and direction should be selected considering the order of the transition process, economic aspect, and social role. From a medical provider's perspective, the course of treatment should be determined as a method that can maximize the safety of patient's voice and minimize side effects while feminizing the voice. The review has determined that the requested Vocal Feminization Surgery, Unlisted procedure, larynx (31599) is medically necessary and reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vocal Feminization Surgery, Unlisted procedure, larynx (31599) have been met. Therefore, we decided that the Plan has to pre-approve outpatient Vocal Feminization Surgery, unlisted procedure, larynx.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist services provided by an out of network (OON) 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 an out-of-network 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 had network providers available who could have provided 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 specialist services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair quick adjustment arm rests (K0108) and
pouches (K0108).

You asked the Plan to pre-approve the wheelchair arm rests and pouches. You say that the accessories are
medically necessary. The Plan denied your request. The Plan says the arm rests are not properly coded, and the
pouches are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for items that have
a specific HCPCS code. Rules also say items that are not medically necessary are not covered.

We looked at the file and Medicare rules. The arm rests have a specific code. K0108 cannot be billed for
wheelchair accessories that have specific codes. Furthermore, the requested pouches are not primarily medical
in nature and are not covered. Based on this information, we decided that Medicare rules for coverage of the
wheelchair arm rests and pouches have not been met. Therefore, we decided that the Plan does not have to preapprove
wheelchair quick adjustment arm rests (K0108) and pouches (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services to you on November 13, 2020.

You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says this is not a
covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are provided by an in-network provider.

We looked at the file and the Plan's rules. The requested vision services were provided to you by an out-of network
provider. The Plan does not cover out-of-network vision care. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan
does not have to pay for the vision services to you on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services by an out of network (OON) provider.

You asked the Plan to pay for the laboratory 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 a covered benefit.

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 had network providers available who could have provided 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 laboratory services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that your doctor was not aware of and did not send in a referral. You say you did not go to any appointment without a referral from your doctor. The Plan denied your request. The Plan says no prior authorization was obtained.

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 office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 22, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy (brachytherapy)for the enrollee.

You asked the Plan to pre-approve radiation therapy (brachytherapy). You say that this treatment is medically
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary. We asked our physician
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was
correct in denying the request to pre-approve radiation therapy (brachytherapy). Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found this case is particularly challenging. For high-risk prostate cancer, brachytherapy alone does not
follow the recommendations of NCCN guidelines, AUA/ASTRO/SUO Guidelines or American Society of
Clinical Oncology/Cancer Care Ontario Joint Guidelines. Nevertheless, there are data to support its use, as well
as abundant data that combined modality brachytherapy and external beam radiation increases risks of toxicity.
This is the primary argument that this patient's oncologist is making- we well as the more cost-effective
treatment as opposed to combined modality approach. Also, none of the guidelines explicitly stat that
brachytherapy alone is not appropriate, but rather do not specifically include it as a recommended treatment or
do not discuss it. Given these factors, it is debatable whether or not brachytherapy alone would be furnished in
accordance with accepted standards of care. Given that some experts would consider it an appropriate treatment
in well-selected patients, it can be argued that the criteria of being furnished in accordance with accepted
standards of care is met. Therefore, medical necessity has been established. We looked at this physician's
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
radiation therapy (brachytherapy) have been met. Therefore, we decided that the Plan has to pre-approve
radiation therapy (brachytherapy)for the enrollee.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty for a restorative procedure
(D4212) provided on February 26, 2020.

You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that you feel these charges were
unfair and unfounded, and that this care is too costly. The Plan denied your request. The Plan says they agree
that the services billed for $10 were charged incorrectly and will be covered, however the gingivectomy or
gingivoplasty service is not covered by Medicare or your 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 the
gingivectomy or gingivoplasty for a restorative procedure (D4212) provided on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services.

You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says
the claim processed 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 $325
copay per day for days 1-5 for inpatient hospital care.

You have been asked to pay a $325 copay each day for the services provided. The services fall within the
inpatient hospital care 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 copay for the inpatient
hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120) provided October 26, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you used the same dentist you have used in the past and were not informed that the services would no longer be covered. The Plan denied your request. The Plan says services were provided by an OON provider and therefore are not covered.

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 prophylaxis and periodic oral evaluations only when the services are provided by a network provider. In this case, the services were provided out of network. The Plan had network providers available to provide the services at issue. We found no exception that would require the Plan to approve OON services. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120) provided October 26, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing coded G2023 and U0003.

You asked the Plan to pay for the COVID-19 testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes G2023 and U0003 are not supported in the medical record. Specifically, these codes
were not billed with the appropriate primary, first listed or principal diagnosis. Based on this information, we
decided that Medicare rules for coverage of the COVID-19 testing have not been met. Therefore, we decided
that the Plan does not have to pay for the COVID-19 testing coded G2023 and U0003.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services you received on December 15, 2020.

You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in-network provider. 

We looked at the file and the Plan's rules. The requested vision services were provided to you by an out-of-network provider. Out-of-network vision services are not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services you received on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on October 28, 2020.

You asked the Plan to waive the copayment for lab work. You say that this copayment should be waived. 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 $20 copayment for outpatient diagnostic tests/laboratory tests. 

You have been asked to pay a $20 copayment for lab work. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit you had on September 9, 2020.

You asked the Plan to pay for the wellness visit. The Plan denied your request. The Plan says the benefit limit has been reached.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided on January 9, 2020, less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the wellness visit you had on September 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy provided on October 12, 2020.

You asked the Plan to waive the coinsurance for the chemotherapy. You say that you would like to appeal the services there were not covered by insurance. 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 20% coinsurance for in-network Medicare-covered Part B drugs dispensed at a retail pharmacy, mail order pharmacy, physician office, and outpatient facility. 

You have been asked to pay $897.29 which is 20% of the allowed amount for the chemotherapy. The allowed amount is $4,486.38. ($4,486.38 x 20% = $897.29). The chemotherapy falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy provided on October 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided August 27, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 2 units of CPT code 97530 are not supported in the medical record. The medical record only supports 1 units of CPT code 97530. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 9, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not urgent/emergent.

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 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 services provided to you by an out-of-network provider on October 9, 2020.