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

We decided that the Plan does not have to pay for a shoulder arthroscopy (29824) provided August 21, 2019.
You asked the Plan to pay for a shoulder arthroscopy. You say that the service provided was medically necessary. The Plan denied your request. The Plan says the billed service 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. 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 a shoulder arthroscopy. Our reviewer says that a shoulder arthroscopy is not supported by the medical records. Our physician reviewer found the medical records provided do not include adequate documentation to corroborate that an arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) was performed on the enrollee on August 21, 2019.
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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder arthroscopy (29824) provided August 21, 2019.
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 criteria for IRF admission have not been met.
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 skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for an MRI. The Plan denied your request. The Plan says the requested MRI is not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of lumbo-sacral neuritis and reports chronic pain in her right leg with ambulation. There is no reported numbness. A physical examination dated February 21, 2020 documents no abnormalities. There is no reference to previous imaging, conservative treatments, of differential diagnosis. Without the support of the documentation, medical necessity cannot be determined. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture (D5110) and lower partial denture provided November 25, 2019.
You asked the Plan to pay for the dental services. You say that the provider's office had told you that you were approved for the cleanings, extractions and dentures. You would not have done the procedure had you known the dentures were not covered. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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 complete upper denture (D5110) and lower partial denture provided November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 30, 2019 to October 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 subsequent nursing facility care provided on September 30, 2019 to October 11, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) and Fluciclovine f-18.
You asked the Plan to pre-approve the PET/CT scan and the Fluciclovine f-18. You say that the enrollee has prostate cancer and wants to make sure it has not spread. You say that the enrollee needs to be on treatment. The Plan denied your request. The Plan says the requested service is not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. Medicare rules also say the only radiopharmaceutical diagnostic imaging agents covered by Medicare for PET cancer imaging are 2-[F-18] Fluoro-D-Glucose (FDG) and NaF-18 (sodium fluoride-18). 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 PET/CT scan and the Fluciclovine f-18. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have an indication for which a PET scan can be covered at this time. CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. 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 PET/CT scan and the Fluciclovine f-18 have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) and Fluciclovine f-18.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe physician services provided on September 25, 2019.You asked the Plan to waive the copayment forthe physician services. You say that you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says that you received physician services on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 have no cost share for a Depression Screening and Screening for alcohol.The Plan says you must pay a $10 copayment for the physician services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the depression and alcohol screenings.Therefore, we decided that the Plan has to waive the copayment forthe physician services provided on September 25, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown on tooth #3.You asked the Plan to pre-approvethe crown. You say that you need these services.The Plan denied your request. The Plan says the x-rays requested were not received within 14 days.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found in general, crowns are not indicted in cases where there is not extensive loss of tooth structure, usually in the area of 50%. Our reviewer found that there is less than 40% damage to the molar tooth, and it would be reasonably restored with a conventional restoration. Our reviewer found that there is sufficient strength remaining in the tooth such that a crown is not necessary. Our physician reviewer also found that given the lack of necessity for a full coveragerestoration and the lack of coverage under the Plan for such a procedure, there is no medical necessity for the requested crown.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown on tooth #3.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forCPT code 74420 under claim number "x" provided on August 28, 2019.You asked the Plan to pay forCPT code 74420 under claim number "x". You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plansays that they were unable to make a determination within the allotted time frame.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan is denying payment for CPT code 74420 underclaim number 820192531155950 as a duplicate of a charge considered for payment on a previous claim. However, the Plan has not provided any other claim for review to support the Plan's rationale for denial of payment.Therefore, we decided that the Plan has to pay forCPT code 74420 under claim number "x" provided on August 28, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay  physician services provided to the enrollee. You asked the Plan to pay this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says a status indicator "C" inpatient procedure HCPCS code 11005 was billed on an outpatient claim. The inpatient procedure does not meet the exception 1 as defined in Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS), Section 180.7 Inpatient-only Services. Procedure code 11005 is listed as an inpatient procedure but is not found on the inpatient separate procedure list and per the exception 1 description. The Plan states a corrected claim would be reviewed if submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case an inpatient code was billed for an enrollee treated in an outpatient setting. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay  for physician services billed to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy services provided from August 29, 2019 to September 2, 2019.You asked the Plan to waive the copayment forthe physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received physical therapy services on the dates of service at issue in this appeal. The Plan states the correct copayments have applied per your contract with the Plan.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 Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received physical therapy services from August 29, 2019 to September 2, 2019. You have been asked to pay a $20 copayment for each physical therapy service. The physical therapy 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 copayment forthe physical therapy services provided from August 29, 2019 to September 2, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveuse of Feraheme (ferumoxytol).You asked the Plan to pre-approveFeraheme. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the treating physician did not say that the enrollee cannot take iron orally and Feraheme is for patients who are unable to take or have had poor response to oral iron.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 Feraheme. Our reviewer says that the enrollee meets the Medicare criteria for Feraheme. Our physician reviewer found the enrollee has symptomatic iron deficiency anemia with reported poor response to prior intravenous iron. Patients that are symptomatic require more immediate treatment to improve anemia than is expected with oral iron. In addition, a poor response to intravenous iron indicates possible ongoing bleeding for which additional intravenous iron is likely to be effective. Therefore, the requested Feraheme is 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 Feraheme have been met.Therefore, we decided that the Plan has to pre-approveuse of Feraheme (ferumoxytol).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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forbreast surgery and drugs provided on September 6, 2019.You asked the Plan to waive the copayment forthe breast surgery and drugs. You say that you are receiving additional charges for an outpatient procedure.The Plan denied your request. The Plan says the copayments 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 $150 copayment for in-network outpatient surgery and a $50 copayment for Part B drugs that are administered by a provider.You have been asked to pay a $150 copayment for the breast surgery. You have also been asked to pay $44.64, which is less than the standard $50 copayment for the drugs. The total amount you owe is $194.64 ($150 +$44.64 = $194.64). The breast surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The drugs fall within the "Medicare Part B prescription drugs" 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 nothave to waive the copayment forbreast surgery and drugs provided on September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infliximab injections provided from May 10, 2019 through May 31, 2019.
You asked the Plan to waive the coinsurance for the infliximab injections. You say that you don't have the money left over to pay. You say that you need help with the bills. 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% of the Medicare-allowed amount for Medicare Part B-covered drugs and chemotherapy drugs from an in-network provider. You have been asked to pay $908.78, which is less than the standard 20% coinsurance for the infliximab injections. The infliximab injections fall within the "Medicare Part B prescription drugs" 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 the infliximab injections provided from May 10, 2019 through May 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapeutic exercises and therapeutic activities provided from August 6, 2019 to August 15, 2019 by an OON provider.You asked the Plan to payforthe therapeutic exercises and therapeutic activities. The Plan denied your request. The Plan says the rendering provider is a non-network provider. The Plan also says that the enrollee was referred by a non-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 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 forthe therapeutic exercises and therapeutic activities provided from August 6, 2019 to August 15, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision for implantation of neurostimulator electrode array, insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, fluoroscopy, and patient documented not to have experienced any events on discharge provided on April 9, 2019 by an OON provider.
You asked the Plan to pay for the medical services. You say that you were told that no pre-authorization was required. The Plan denied your request. The Plan says the rendering provider is a non-network provider who does not work with the enrollee's health plan. The Plan also says that the enrollee self-directed for care.
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 incision for implantation of neurostimulator electrode array, insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, fluoroscopy, and patient documented not to have experienced any events on discharge provided on April 9, 2019 by an OON provider.