Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hysteroscopy biopsy (58558) provided on October 19, 2020.
You asked the Plan to waive the copayment for the hysteroscopy biopsy. You say that you received a letter stating that all cancer tests were covered with no cost sharing or coinsurance required. The Plan denied your request. The Plan says there is a $350 copayment for outpatient surgery, services, and procedures provided at a hospital outpatient facility.
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 $350 copayment for outpatient surgery, services and procedures provided in an outpatient hospital facility. You have been asked to pay a $350 copayment for a hysteroscopy biopsy, which was performed at an outpatient hospital facility. A hysteroscopy biopsy falls within the outpatient surgery, services and procedures benefit category. This particular procedure was provided by an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. Please note that while certain cancer screenings (such as a pap test and pelvic exam) are covered with no copay or coinsurance, a hysteroscopy is a separate type of diagnostic exam and is different from a cancer screening. 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 hysteroscopy biopsy (58558) provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anterior instrumentation (22845) provided on June 30, 2020.
You asked the Plan to pay for anterior instrumentation. You say that this is supported in the record. The Plan denied your request. The Plan says this is not documented in the operative report.
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 22845 is anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure). 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 anterior instrumentation. Our reviewer says that this code is not supported in the records. Our physician reviewer found anterior instrumentation of 2 to 3 vetebral segments was not documented in the operative report. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anterior instrumentation have not been met. Therefore, we decided that the Plan does not have to pay for anterior instrumentation (22845) provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says a benefit exception cannot be made.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not have a covered indication for hyperbaric oxygen
therapy. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSurgical Dressings (foam dressing with adhesive border and sterile gauze) to be used as ostomy supplies.You asked the Plan to pre-approvethe surgical dressings. You say that the dressings are necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical dressings have not been met. Your physician ordered surgical dressings to manage your ostomy instead of ostomy supplies. Surgical dressings such as sterile gauze and foam dressings are used to cover wounds caused by a surgical procedure or after debridement (removal of dead tissue) of a wound. You have an ostomy (a hole created in surgery to allow for urine to stool to leave your body). Your ostomyis not considered a wound. Therefore, there is no coverage for the requested dressings.Therefore, we decided that the Plan does not have to pre-approveSurgical Dressings (foam dressing with adhesive border and sterile gauze) to be used as ostomy supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2020 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 rendered 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 on June 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe naturopath services provided on June 30, 2020.You asked the Plan to pay forthe naturopath services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says services provided by a naturopath are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services.Therefore, we decided that the Plan does not have to pay forthe naturopath services provided on June 30, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs close physician management, nurse monitoring, and rehab therapy.The Plan denied your request. The Plan says the enrollee does not need close physician care, or aninterdisciplinary team for rehab care.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 physician reviewer found that the enrollee was admitted to the acute hospital for foot pain after a mechanical ground level fall. Fractures of 2-4 metatarsalswere treated non-operatively. The enrollee's medical conditions are stable. The complexity of hisnursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.Hedoes not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor, transmitter, and receiver (HCPCS A9276, A9277, and A9278)You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no evidence of a trial and failure of traditional glucose monitoring.The Plan must follow Medicare rules. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes.The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor, transmitter, and receiver (HCPCS A9276, A9277, and A9278)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthotics rendered on May 29, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plandoes not have to pay forthe orthotics rendered on May 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to cover the Covid-19 (SARS-CoV-2) test administered on May 29, 2020.
You asked the Plan to cover the Covid-19 test. You say that that you should not be billed for having a test during a pandemic, and that you needed to have the test done for work. The Plan denied your request. The Plan says testing is not covered when administered to assess health status in an asymptomatic individual as required by an employer.
The rules say that routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Covid-19 test have not been met. Specifically, the record shows that this service was needed as a requirement of a third party. This means that the service at issue is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the Covid-19 (SARS-CoV-2) test administered on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services forward.

You asked the Plan to pre-approve inpatient psychiatric services. 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 medically necessary.

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 psychiatric services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization with Major Depressive Disorder, Recurrent, Severe without Psychotic Features and Cognitive Deficit Is Late Effect of Traumatic Brain Injury. The documentation does not support thatit was expected this enrollee would improve in a reasonable period of time for the dates in question as the enrollee did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. The enrollee did not show any aggressive behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self or others but was compliant with treatment. The enrollee was not showing any aggressive behaviors or any treatment required for acute threats of safety. Therefore, the enrollee does not meet criteria for the requested 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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services from February 11, 2021 forward
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on September 24, 2020.
You asked the Plan to pay for the endodontic therapy. You say that your tooth was infected, and you could not
wait to treat it until you got better coverage. The Plan denied your request. The Plan says this service is 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.
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
endodontic therapy provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for whole body bone and joint imaging (78306) provided on November 23, 2020.
You asked the Plan to waive the copayment for bone and joint imaging. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $200 copayment after the $750 deductible is met for each advanced imaging service for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $10 out of the $200 copayment for advanced diagnostic tests plus $129.47 for the remaining $750 deductible. 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 whole body bone and joint imaging (78306) provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 9, 2020.You asked the Plan to pay forthe dental services. You say that youwere not made aware that the provider had opted out of Medicare. You say that you were told that they accept your plan. You also say that you were scheduled for another appointment.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services provided by a dentist who has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services provided from May 11, 2020, to May 12, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the billed services cannot be verified.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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)We find that CPT code 99292 is not supported in the medical record. Specifically, the records do not show that an additional 30 minutes of critical care services were provided beyond the initial 74 minutes. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services provided from May 11, 2020, to May 12, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a ClariFix procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that there is insufficient published evidence to assess the safety or impact on health outcomes.
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 the requested services. Our physician reviewer found that the enrollee was previously diagnosed with vasomotor rhinitis. He reports that his rhinitis was worsening. The nasal exam showed mucoid drainage from both nares. He had a computed tomography (CT) scan which showed no evidence of acute sinusitis. It is unclear how long he has had vasomotor rhinitis or whether he has used Atrovent nasal spray. Previously, the only surgical option was that the vidian nerve was transected. The ClariFix device uses a novel technique, which is to cryoablate the nerve. A study was done reviewing the outcomes of this procedure. Symptoms were significantly decreased and remained lower at 30, 90, 180, and 365 days after the procedure. Although the ClariFix device is new, it should not 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve a ClariFix procedure.
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 the medical services provided on July 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the tissue exam and special stain (88305 and 88312). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are network providers available who can render 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 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 on July 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (CPT Code 22869).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (CPT Code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve these services. You say that you are paralyzed on the left side and have no upper body strength. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.