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

We decided that the Plan has to pre-approve a myocardial perfusion imaging study (78452).
You asked the Plan to pre-approve a myocardial perfusion imaging study. You say that the service is necessary.
The Plan denied your request. The Plan says that medical necessity has not been established. Therefore,
coverage criteria has not been 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 a myocardial perfusion imaging study.
Our reviewer says that the requested services are considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation supports that a SPECT myocardial perfusion imaging study is
medically reasonable and necessary for the enrollee in this case, as he has symptoms which suggest potential
coronary artery disease, and it is noted that a treadmill stress test would not be a safe option for him.
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 myocardial perfusion imaging study have been met. Therefore, we decided
that the Plan has to pre-approve a myocardial perfusion imaging study (78452).
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-network.
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 a referral to the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on September 4, 2019 by the out of network provider.
You asked the Plan to pay for the dental services. You say that you received the service in network. You also say that the service was under your 6 month preventive dental exam. The Plan denied your request. The Plan says gingival irrigation is not a covered service.
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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on September 4, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 27, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the labs should be included in the annual physical. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for laboratory tests. You have been asked to pay the allowed amount of $10.16, which is less than the $20 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and gradient compression wrap identified with code A6545.
You asked the Plan to pre-approve the compression stockings and gradient compression wrap. You say that you have been using compression stockings since 1995 because they put pressure on the leg and keeps the lymphedema from getting worse. The Plan denied your request. The Plan says these items are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and A6545 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and gradient compression wrap identified with code A6545.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound debridement provided from December 4, 2018 to December 24, 2018.
You asked the Plan to waive the coinsurance for wound debridement. You say that you disagree with the high charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 surgery services provided in an outpatient hospital facility. You received wound debridement from December 4, 2018 to December 24, 2018. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the costs-sharing charges. The total allowed amount is $1,196.64 and 20% of that is $239.34. You have been asked to pay the total coinsurance amount of $239.34 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 wound debridement provided from December 4, 2018 to December 24, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CT scan and contrast material provided on October 1, 2019.
You asked the Plan to waive the cost share for the CT scan and contrast material. You say that your doctor was not satisfied with the report. You say that you should not be responsible for paying. The Plan denied your request. The Plan says the cost share applied 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 $100 copayment for each Medicare-covered radiological diagnostic service performed in an in-network physician's office or at a free-standing facility and 20% coinsurance for each Medicare-covered medical supply. You have been asked to pay $101.54 for the CT scan and contrast material.
Service
Allowed Amount
Standard Cost
Member Liability
CT Scan
$219.24
$100
$100
Contrast Material
$7.70
20%
$1.54
TOTAL:
$101.54
The CT scan and contrast material fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the CT scan and contrast material provided on October 1, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (pembrolizumab) with addition of carboplatin and paclitaxel.
You asked the Plan to pre-approve the requested chemotherapy regimen. You say that the enrollee had rapid progression on Keytruda monotherapy which is why it is felt that adding platinum-based chemotherapy would be beneficial. The Plan denied your request. The Plan says that continuation of Keytruda is not covered because it did not immediately work.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested chemotherapy regimen. Our reviewer says that the requested chemotherapy plus immunotherapy regimen is considered reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with metastatic non-small cell lung cancer (NSCLC), PD-L1 of over 90%. A PET scan on 2/3/2020 showed significant progression after several cycles of Keytruda as monotherapy. The request at issue is to add carboplatin and paclitaxel chemotherapy. There is some data that chemotherapy plus Keytruda is more effective for rapid progression. 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 chemotherapy regimen have been met. Therefore, we decided that the Plan has to pre-approve Keytruda (pembrolizumab) with addition of carboplatin and paclitaxel.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have chronic foot pain whenever you walk.
The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you have swelling and
discoloration in your feet, and the stockings will help with circulation. The Plan denied your request. The Plan
says this item is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Flexitouch pneumatic compression device and garments.
You asked the Plan to provide a pneumatic compression device (E0652) and garments (E0667). You say that
the Flexitouch pneumatic compression device will meet the enrollee's needs. The Plan denied your request. The
Plan says the enrollee has not had a four week trial with a basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to provide a Flexitouch pneumatic compression
device and garments.
Appeal type: Home Health
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 these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for 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 waive the copayment for an ear biopsy and wound debridement.
You asked the Plan to waive the copayment for an ear biopsy and wound debridement. You say that you feel
that you should only owe a $35 copayment. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $295
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received an ear biopsy and wound debridement. An ear biopsy and wound
debridement is considered outpatient surgical procedures. Therefore, you are responsible to pay the allowed
amount of $109.27.
You have been asked to pay $109.27 for an ear biopsy and wound debridement. An ear biopsy and wound
debridement fall within the outpatient surgery and other medical services provided at hospital outpatient
facilities and ambulatory surgical centers 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 an ear biopsy and wound debridement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular
partial denture (D5214).
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you are having trouble eating and it is imperative that you have your teeth fixed. You also say that you need
new dentures because of severe weight loss and tooth extractions which make your current dentures unusable.
The Plan denied your request. The Plan says you have exceeded the limits set in the subscriber agreement.
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 replacement of dentures is limited
to 1 time every consecutive 5 years. The record shows that you received a complete maxillary denture and a
mandibular partial denture and your dentures benefit is now exhausted. Therefore, we
decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular
partial denture (D5214).
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 enrollee is a good candidate for IRF. The Plan
denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee's condition appears stable with no complex wound care needs. The
enrollee does not require oversight of her condition at the acute inpatient rehabilitation hospital level of care.
The enrollee does require physical therapy for mobility and occupational therapy for remaining activities of
daily living. However, there is not a reasonable expectation that the enrollee would be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. The enrollee's care can be
appropriately provided at a skilled nursing facility level of care.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desvenlafaxine Succinate ER for the enrollee.
You asked the Plan to pre-approve Desvenlafaxine Succinate ER. The Plan denied your request. The Plan says
that this is not covered under 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 Desvenlafaxine Succinate
ER for the enrollee.
Benefits for Desvenlafaxine Succinate ER 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: Favorable

We decided that the Plan has to pay for ophthalmological services provided.
You asked the Plan to pay for the ophthalmological services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says that when the number of units
billed per day for a member on a single claim or across multiple claims exceeds the assigned maximum
allowable for a given CPT or HCPCS code, then the total number of units will be adjusted to the assigned
maximum allowed amount and the excess units will be denied.
The Plan must follow Medicare rules. Medicare rules say that an MUE for a HCPCS/CPT code is the
maximum number of units of service under most circumstances allowable by the same provider for the same
enrollee on the same date of service.
We find that CPT code 92014 is supported in the record. Specifically, 92014 has an MAI of 3 meaning it is
unlikely for the service to be rendered twice in a day by the same provider. The claims at issue were billed by
two separate providers and indicate different primary diagnoses. The records indicate the member received
ophthalmology services for glaucoma and was then urgently seen by another provider for the new onset
hypotony. Based on this information, we decided that Medicare rules for coverage of the ophthalmological
services have been met. Therefore, we decided that the Plan has to pay for ophthalmological services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT (LDCT) scan of the chest for lung cancer
screening.
You asked the Plan to pre-approve the LDCT screening. You say that this screening is needed due to the
enrollee's shortness of breath. The Plan denied your request. The Plan says in this case, the enrollee is not
asymptomatic. With his risk factors and new onset shortness of breath, the best option is a diagnostic CT scan
of the chest, and not an LDCT scan screening.
The Plan must follow Medicare rules. Medicare rules say that LDCT imaging for lung cancer screening is
covered for those are meet certain criteria and are asymptomatic.
In this case, the enrollee has shortness of breath on exertion. This is a potential sign/symptom of lung cancer
and means that this screening test is not covered by Medicare. Therefore, we decided that the Plan does not
have to pre-approve a low dose CT (LDCT) scan of the chest for lung cancer screening.