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

We decided that the Plan does not have to pay for the surgical services rendered to enrollee on September 13, 2019.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 procedure code 29828-RT is not supported.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 29828-RT is arthroscopy, shoulder, surgical; biceps tenodesis.We find that CPT code 29828-RT is not supported in the medical record. Specifically, there is no documentation of a surgical shoulder arthroscopy with biceps tenodesis. 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 pay for the surgical services rendered to enrollee on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arikayce.
You asked the Plan to pre-approve Arikayce. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Arikayce is not covered under the enrollee's Medicare Part B
benefit. The Plan states they believe the enrollee's pharmacy benefit manager is Silver Scripts or Express
Scripts.
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 Arikayce.
Benefits for Arikayce 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for urethra surgery provided on August 3, 2018.
You asked the Plan to waive the coinsurance for urethra surgery. You say that he should have been kept overnight. You say that the bill should be taken care of. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges.
You have been asked to pay $3,186.95, which is 20% of the allowed amount for urethra surgery. The allowed amount is $15,934.76 (20% x $15,934.76 = $3,186.95). Urethra surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the surgery was performed. 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 urethra surgery provided on August 3, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a topical application of fluoride varnish (D1206), periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), periodontal maintenance (D4910), and gingival irrigation (D4921 x 3).You asked the Plan to pre-approvethe dental services. You say that a deep cleaning will help prevent an infection.The Plan denied your request. The Plan says the requested dental services are not listed as 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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea topical application of fluoride varnish (D1206), periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), periodontal maintenance (D4910), and gingival irrigation (D4921 x 3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COPD and pneumonia. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a clasp to an existing partial denture (D5660) provided on October 16, 2019.
You asked the Plan to pay for the dental service. You say that since some payment was allowed on the removal, there should also be some payment on putting it back on your partial. The Plan denied your request. The Plan says denture repairs are covered once per year. The Plan also says the frequency limit for denture repairs has been exceeded.
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 and denture repairs are a covered service, the frequency limit has been exceeded. The record shows that the Plan already paid for a denture repair (the addition of a tooth to an existing partial denture) that you received on October 16, 2019. Therefore, we decided that the Plan does not have to pay for the addition of a clasp to an existing partial denture (D5660) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facilitycare providedon June 27, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicarerules 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 subsequent nursing facilitycare providedon June 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require 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.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 24, 2019.You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio test strips for the enrollee.
You asked the Plan to pre-approve these services. You say that the Plan denied your request. The Plan says that
there is no medical reason documented that you are medically unable to use the preferred meters.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.
The items at issue are One Touch Verio test strips. One Touch Verio is not a preferred provider with the Plan
for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers. Therefore, we decided that the
Plan does not have to pre-approve One Touch Verio test strips for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve peroral endoscopic myotomy (PEOM) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies have not proven that the procedure is helpful for treatment of stage 2 achalasia (swallowing disorder).
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is not investigational for the enrollee's indication, has proven efficacy, and is medically necessary (with greater likelihood of benefit and safety than available standard approaches) for treatment of the enrollee's 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 the services have been met. Therefore, we decided that the Plan has to pre-approve peroral endoscopic myotomy (PEOM) for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 10, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthosis was not met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pay for the lumbar-sacral orthosis (L0650). Our physician reviewer found theenrollee's chief complaint was back pain, as well as knee pain and shoulder pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, asthere is insufficient documentation of a credible physical examination of the back.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 lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that the enrollee requires frequent changes in body position which is not possible using an ordinary bed.The Plan denied your request. The Plan says the total electric hospital bed is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on October 8, 2019.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 testing is not covered. The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.We looked at the file and Medicare rules. The file shows that the enrollee did not have a previous cancer-negative prostate biopsy within 24 months with consideration for a repeat biopsy due to persistent or elevated cancer risk-factors. 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 pay for the ConfirmMDx testing rendered on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the requested orthotics would allow you to walk and do the necessities that life requires. You say that you need the orthotics in order to live a normal live and you cannot afford to pay for it.The Plan denied your request. The Plan saysthis 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 thePlan does not have to pre-approvefoot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveUdenyca.You asked the Plan to pre-approveUdenyca. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plansays the cost of services received as part of a Medicare-approved clinical trial is covered by Original Medicare and not by the enrollee's Medicare Advantage Plan.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicareand the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve Udenyca as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approveUdenyca.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
You asked the Plan to pre-approve the consultation and extraction. You say that you need these services to be provided by an oral surgeon. The Plan denied your request. The Plan says the Plan offers supplemental dental benefits in excess of Medicare, which includes one simple extraction or surgical removal of an erupted tooth, when performed by a participating general dentist. The Plan also says that dental services provided by specialists, such as oral surgeons, periodontists, orthodontists, prosthodontists, and endodontists are not covered by the Plan.
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 when they are not performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy duty extra wide hospital bed.You asked the Plan to pre-approvethe requested bed. You say that the enrollee cannot move around in his current bed.The Plan denied your request. The Plan says the enrollee's weight is well below the minimum requirement for this item.The Plan must follow Medicare rules. Medicare rules say that aheavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.We looked at the file and Medicare rules. The records provided do not indicate that the enrollee's weight is more than 350 pounds, but does not exceed 600 pounds. Based on this information, we decided that Medicare rules for coverage of the requested bed have not been met. Therefore, we decided that the Plan does not have to pre-approvea heavy duty extra wide hospital bed
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest, in the setting of advanced liver disease. The enrollee is not intubated/ventilated. The enrollee is noted to have a poor long-term prognosis. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided by Out of Network provider (OON) from September 3, 2019 to September 30, 2019.You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not informed you would owe a copayment and you disagree with the 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 a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services provided by September 3, 2019 to September 30, 2019 for a total of 7 visits. Therefore, you are responsible to pay your share of the cost-sharing charges. The total amount you owe is: $40 (copayment) x 7 (PT visits) = $280.You have been asked to pay the total copayment amount of $280for outpatient rehabilitation services. Outpatient rehabilitation services fall 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 copayments for outpatient rehabilitation services provided by Out of Network provider (OON) from September 3, 2019 to September 30, 2019.