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

We decided that the Plan has to pre-approve a porcelain crown (D6750), retainer crown (D6740), and core
buildup (D2950) for the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says that the submitted narrative fails to support any specific physical or
psychological condition that precludes the use of a removable prosthesis.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan has not substantiated their denial. They have provided a medical (rather
than administrative) denial but have not provided any x-rays or dental records for us to review. It
cannot be determined if their denial reason is valid in this case. Therefore, we decided that the Plan has to preapprove
a porcelain crown (D6750), retainer crown (D6740), and core buildup (D2950) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the F1Heme test is a proven medically necessary covered benefit.The Plan denied your request. The Plan says utilization of network providers when possible and available.

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 medical services provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system. You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the enrollee is with a history of obesity, sleep apnea, hypertension, hyperlipidemia, diabetes, gout, breast cancer and NYHA Class III congestive heart failure with preserved LV ejection fraction (LVEF 65%) requiring hospital admission. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or 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 CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on September 10, 2020.You asked the Plan to waivethe copayment forthe specialist office visit. You say that if the doctor had only performed the PAP smear, you would not be charged a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.Therules 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 $40 copayment for provider and professional services for in-network specialist's office. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.The record shows you received other services during your visit.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 specialist office visit provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea knee orthosis (L1843).You asked the Planto pre-approvethe orthosis. You say that the records do not show any of the covered indications.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of knee instability on exam. There is no recent injury or injury to the knee. There was no documentation of significant varus/valgus on exam. Therefore, the request for the knee orthosis is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea knee orthosis (L1843)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 16, 2020 to March 17, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the admitting physician determined that the safest, most appropriate and medically necessary course of treatment was to admit this enrollee to the hospital as an inpatient.The Plan denied your request. The Plan says the records do not meet medical necessity for inpatient level of care and observation status is appropriate.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee presented to the ER with progressive headache associated with weakness and vomiting that started in the ED. She was treated with IVF, Zofran and oral Meclizine. She was admitted because she had persistent symptoms of vertigo. The review has determined that the record did not show that at the time ofinpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 16, 2020 to March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services received on November 27, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe benefit maximum was reached before the date of service in question.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 pays for dental services with an annual maximum of $1,000.The full maximum was reached on November 27, 2019. Any further dental charges are your responsibility. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordental services received on November 27, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an Integra skin substitute.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee suffered an open fracture of the
middle phalanx of his right middle finger and a laceration of the extensor tendon. He has failed two prior
primary repairs of the extensor tendon and the wound has dehisced and the tendon is visualized. The Integra
skin substitute is not experimental in nature. Integra is an artificial skin substitute that is used in the clinical
treatment of wounds of different etiologies, chronic wounds, and in soft tissue defects. In this case, the enrollee
has a wound where two prior repairs were unsuccessful. The use of a skin substitute is medically reasonable
and necessary in this 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 these services have been met. Therefore, we decided that the Plan has to preapprove
an Integra skin substitute.
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 waive the copay for the urgent care services provided on October 7, 2020.
You asked the Plan to waive the copay for the services provided. You say that the Covid test should be free of charge. The Plan denied your request. The Plan says the claim for services 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 $50 copay for each urgent care visit. You have been asked to pay a $50 copay for the services provided. The services fall within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the urgent care services provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional power wheelchair accessories (E2311, E2377, E2311, K0108) for the enrollee.You asked the Plan to pre-approvethe accessories. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found K0108 fluid supplement is not medically necessary as it exceeds the enrollee's medical needs. The enrollee was approved an E2622 skin protect wheelchair seat cushion and an E2620 back cushion already. The K0108 is not medically necessary as the wheelchair seat and back approved codes are all inclusive. The E2377 Expandable Controller and E2313 Expandable Controller Harness and E2311 are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504). 
The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 ormore powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and functional ability are sufficient to control any power options through their own switches.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 accessories have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional power wheelchair accessories (E2311, E2377, E2311, K0108) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcomputed tomography (CT) scans (70498, 71045, 71275, 72125, 72128, 72131, 72170, and 74174) provided on September 17, 2019.You asked the Plan to pay forCT scans. You say that the procedures are supported in the records.The Plan denied your request. The Plan says these procedures are not documented.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 70498, 71045, 71275, 72125, 72128, 72131, 72170, and 74174 are not supported in the medical record. Specifically, the submitted medical records only include documentation of on CT scan of the brain, which was paid under CPT code 70450. There is no documentation of other CT scans being performed. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met.Therefore, we decided that the Plan does not have to pay forcomputed tomography (CT) scans (70498, 71045, 71275, 72125, 72128, 72131, 72170, and 74174) provided on September 17, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency ambulance transportation (A0429) provided on October 1, 2020.You asked the Plan to waive the copayment forambulance transportation. You say that you should not have a copayment.The Plan denied your request. The Plan says ambulance transportation has a $250 copay.The rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance transportation. You have been asked to pay a $250 copayment for ambulance transportation. Ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foremergency ambulance transportation (A0429) provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy techniques (97140) and the office visit (99212) provided on September 4, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not covered under your contractual policy or by Medicare.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the manual therapy techniques (97140) and the office visit (99212) provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on October 15, 2020.

You asked the Plan to waive the copayment for the physical therapy visit. You say that things were complicated and you needed the therapy. You say the copayment should not apply. 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 $40 copayment for each Medicare-covered therapy visit. 

You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy visit provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided August 4, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel that the copayment is excessive. The Plan denied your request. The Plan says the copayment has applied correctly in this case.
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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for the ambulance services. The services provided fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided on August 7, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not covered.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 63688. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided on August 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for ankle pain and swelling. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.