Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the one copayment for the debridement services provided on March 23, 2020.
You asked the Plan to waive the one copayment for the debridement services. You say that you disagree with being billed two copayments for the same service. The Plan denied your request. The Plan says that the claims have been processed correctly per your plan benefits.
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 enrollees must pay a $30 copayment for podiatry services. The Plan says you must pay a $30 copayment for the debridement services. Based on the Plan contract, however, you cannot be asked to pay more than the one $30 copayment for the debridement services. Therefore, we decided that the Plan has to waive the one copayment for the debridement services provided on March 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent (J3590).
You asked the Plan to pre-approve Dupixent. You say that the enrollee has severe asthma and had been having
exacerbations every couple of months until he started the Dupixent. The Plan denied your request. The Plan
says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent (J3590).
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management
services (99239) provided on October 7, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not support the service billed.
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 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the record. Specifically, the record does not indicate that
more than 30 minutes of hospital discharge day management services were rendered. Based on this
information, we decided that Medicare rules for coverage of the hospital discharge day management services
have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of
hospital discharge day management services (99239) provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextraction of a wisdom tooth with sedation to be provided by an oral surgeon.You asked the Plan to pre-approveextraction of a wisdom tooth with sedation to be provided by an oral surgeon. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveextraction of a wisdom tooth with sedation to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 9, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told that the urgent care facility would not charge you a copayment because you only had your blood pressure taken. 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 $50 copayment for each in and out-of-network urgently needed care visit. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows a physical exam was done which included vitals and measurements.
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 urgent care visit provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services beginning July 10, 2020.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the 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 Medicarerules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 30, 2020 with major neurocognitive disorder with behavioral disturbance and possible Lewy body dementia. Based on the submitted records, it is not expected that the enrollee will improve in a reasonable period of time beyond the dates in question, as he is not showing any dangerousness to self or others and has no auditory or visual hallucinations. He has no acute threats to safety. It does not appear that active treatment is taking place beyond the dates in question. The continued inpatient services are not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services beginning July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 3, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 physician's services providedon March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided on March 26, 2020.
You asked the Plan to pay for genetic tests. You say that your lab performed these tests as ordered by the referring provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnosis listed and were performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The rules say that a physician order or clear intent to order specific lab services is required for covered lab services.
The documentation does not include a valid physician order or clear intent to order these tests for covered purposes. Furthermore, Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided on March 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda.You asked the Plan to pre-approveKeytruda. The Plan denied your request. The Plan says you do not meet medically-accepted standards for the use of the requested drug.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denyingthe request to pre-approve Keytruda. Our physician reviewer found that you have microsatellite stable ovarian cancer. Your cancer has PDL1 expression greater than or equal to1, with a combined score of 3. The requested use is not FDA approved. The requested use is not compendium supported. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore, the requested drug is not considered 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approveKeytruda
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone.You asked the Plan to pre-approvethese services. You say that the medication is needed to control the enrollee's overall symptoms.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDexamethasone.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total of 26 sessions of orthoptic/pleoptic trainings
(including the 12 approved).
You asked the Plan to pre-approve the additional orthoptic/pleoptic training sessions. You say that this type of
training is necessary to assist with the enrollee's vision issues. The Plan denied your request. The Plan says an
initial 12 sessions are approved with further need to be determined based on the results of those visits.
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 additional orthoptic/pleoptic
training sessions. Our reviewer says that the requested number of trainings are not considered medically
reasonable and necessary in this case. Our physician reviewer found additional vision therapy sessions beyond
the 12 weeks approved by the plan are not medically necessary. There is weak to moderate evidence that
office-based vision therapy may be beneficial for children with convergence insufficiency. In this case, the
patient has convergence insufficiency that is possibly related to previous head trauma, or that is age-related.
The available medical evidence does not support the requested number of in-office vision therapy for this
situation. The standard of care in this case would be home exercises to strengthen convergence or prismatic
glasses, or a combination of the two.
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 additional orthoptic/pleoptic training sessions have not been met. Therefore,
we decided that the Plan does not have to pre-approve a total of 26 sessions of orthoptic/pleoptic trainings
(including the 12 approved).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service (A0428) and the ground mileage (A0425) provided on May 10, 2019.
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 Original Medicare is responsible for payment of these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service (A0428) and the ground mileage (A0425) provided on May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by an out of network (OON)
provider.
You asked the Plan to pre-approve hearing aids. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested hearing aids can be provided by a 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-approve
hearing aids 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 crowns (D2740) and core buildup (D2950) for teeth #2, 6, 7, 8, 9, 10, 22, 27, and 31 and core buildup for tooth #28 (D2950).
You asked the Plan to pre-approve crowns and core buildup for teeth #2, 6, 7, 8, 9, 10, 22, 27, and 31 and core buildup for tooth #28. 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 crowns and core buildup for teeth #2, 6, 7, 8, 9, 10, 22, 27, and 31 and core buildup for tooth #28. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found teeth #'s 2, 6, 7, 8, 9, 10, 22, 27 and 31 do not appear to have the significant coronal breakdown to meet the criteria for coverage for crowns or core buildup. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of crowns and core buildup for teeth #2, 6, 7, 8, 9, 10, 22, 27, and 31 and core buildup for tooth #28 have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) and core buildup (D2950) for teeth #2, 6, 7, 8, 9, 10, 22, 27, and 31 and core buildup for tooth #28 (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous Spacer procedure.You asked the Plan to pre-approvea Vertiflex Superion Interspinous Spacer procedure. You say that the requested Vertiflex procedure is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex procedure 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 Vertiflex Superion Interspinous Spacer procedure. Our reviewer says that the requested Vertiflex procedure is not medically necessary. Our physician reviewer found this enrollee presents with a history of chronic low back pain radiating down the lower extremities in a non-dermatomal pattern with associated numbness and tingling in the anterolateral thighs. Functional limitations are noted in activities of daily living. Pain relief is reported with flexion. She has been diagnosed with lumbar spinal stenosis with neurogenic claudication. There is imaging evidence of multilevel moderate to severe stenosis with nerve root compromise from L1/2 to L5/S1. She has reportedly failed over 48 months of conservative treatment. Under consideration is a request for the Vertiflex Superion device at the L4/5 level. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Additionally, FDA indication include implantation of the Superion device at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has moderate to severe central canal stenosis documented at all levels from L1/2 to L5/S1. There is no rationale why standard surgical decompression would not be indicated. Additionally, FDA contraindications include fracture of thepars interarticularis and osteoporosis. There is imaging evidence of pars defects at the L4/5 and L5/S1 levels. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this post-menopausal 70-year-old female. Therefore, thisrequest for Vertiflex Superion indirect lumbar decompression is not reasonable and medically necessary for this enrollee's medical condition.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 Vertiflex Superion Interspinous Spacer procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous Spacer procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show the enrollee requires skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the records received do not indicate that the criteria for coverage of IRF care have been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate to minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. An IRF intensity is not warranted. 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.