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

We decided that the Plan does not have to pre-approve lip repair (40654 and 40650).You asked the Plan to pre-approve lip repair. You say that your lip is at risk of rupturing.The Plan denied your request. The Plan says this is cosmetic.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 lip repair. Our reviewer says that the documentation in the case file does not support that lip repair for venous lakes is medically reasonable and necessary for you in this case. Our reviewer found there is no documentation of bleeding or other medical complications related to the lesions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lip repair have not been met.Therefore, we decided that the Plan does not have to pre-approve lip repair (40654 and 40650).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 26, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the hospital should be responsible for 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 for ambulance services provided on January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on September 24, 2019 and October 1, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you feel that the drug was not effective and feel that the charges should be covered. 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 Medicare Part B prescription drugs. You received Medicare Part B drugs on September 24, 2019 and October 1, 2019. The total allowed amount is $10,086 and 20% of that is $2,017.20. You have been asked to pay the total coinsurance amount of $2,017.20 for Medicare Part B drugs. Medicare Part B 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 not have to waive the coinsurance for Medicare Part B drugs provided on September 24, 2019 and October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 14, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis
(L1833) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the incision and drainage services and office visit provided on December 14, 2019.You asked the Plan to waive the coinsurance for the incision and drainage services and office visit. 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 routine podiatry care and specialist services on the date of service at issue in this appeal. The Plan states the correct coinsurance 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 15% coinsurance for Additional Routine Podiatry and a 15% coinsurance for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received incision and drainage services and a specialist visit on December 14, 2019. You have been asked to pay a 15% coinsurance for the incision and drainage services, totaling $27.13. The incision and drainage services fall within the Additional Routine Podiatry benefit category. You have been asked to pay a 15% coinsurance for the specialist visit, totaling $12.27. The specialist visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 incision and drainage services and office visit provided on December 14, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 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 found to be medically reasonable and necessary for you. Our physician reviewer found you have therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet your rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
September 2, 2019 to September 3, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are missing the FIPS code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the Federal
Information Processing Standard (FIPS) code is required to identify the county where the services were
rendered. Therefore, we decided that the Plan does not have to pay for the home health services provided to the
enrollee from September 2, 2019 to September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Orencia (Abatacept).
You asked the Plan to pre-approve the Orencia (Abatacept).. You say that neither Renflexis or Inflectra can be used due to the presence of Sjogren's Syndrome and rheumatoid arthritis. You also say that Orencia has been shown to be efficacious in treating these symptoms when present together. The Plan denied your request. The Plan says the use of Orencia to treat Sjogren's Syndrome is not a medically accepted indication. The Plan also says that the clinical records show that the enrollee has been doing well on Methotrexate and Plaquenil with limited tolerance for Plaquenil, but positive effects.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Orencia (Abatacept).. Our reviewer says that the Orencia (Abatacept) is not medically necessary. Our physician reviewer found the records support the enrollee is being treated with methotrexate and Plaquenil. The enrollee has not tried the required drugs, Renflexis or Inflectra. Our reviewer found that the review of compendia does not support the use of Orencia for the treatment of Sjogren's syndrome. Our physician reviewer also found that without the support of the compendia or a clear rationale for the requested medication, 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 Orencia (Abatacept). have not been met. Therefore, we decided that the Plan does not have to pre-approve the Orencia (Abatacept).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis,and topical application of fluoride varnish provided on December 5, 2019.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and topical application of fluoride varnish. You say that your previous plan allowed for 4 cleanings per year. You also say that you checked with the Plan prior to the services being rendered and were told they would be covered.The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitations had 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, exams, prophylaxes, and fluoride treatments are each limited to two procedures per calendar year. The record shows that you received an oral evaluation, prophylaxis, and fluoride treatment on February 7, 2019 and August 14, 2019 and your exam, prophylaxis, and fluoride treatment benefits were then exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and topical application of fluoride varnish provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter purchased on August 10, 2019. You asked the Plan to reimburse you for the knee scooter (E0118). You say that while away on vacation you were injured and unable to use crutches so you purchased a knee scooter. The Plan denied your request. The Plan says knee scooters are not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Knee scooters are statutorily excluded by Medicare. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met. Therefore, we decided that the Plan does not have to reimburse you for the knee scooter purchased on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments and coinsurance for the outpatient services provided on October 31, 2019.
You asked the Plan to waive the copayments and coinsurance for the outpatient services. You say that you feel you shouldn't have to pay this much for the outpatient services. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for part B drugs.
Review of the file shows that you are being asked to pay 20% coinsurance for the drugs and injection services for a total of $10.58. You have been asked to pay 20% coinsurance for the medical supplies provided for a total of $2.46. You have been asked to pay a $5 copayment for the basic metabolic panel. You have been asked to pay a $30 copayment for the physical therapy evaluation. You have been asked to pay 20% coinsurance for the MRA for the amount of $303.44. You have been asked to pay 20% coinsurance for the MRI for a total of $196.14. You have been asked to pay 20% coinsurance for the gadolinium based magnetic resonance contrast agent for a total of $8.12. You have been asked to pay 20% coinsurance for the electrocardiogram for a total of $16.81. Lastly, you have been asked to pay a $275 copayment for the outpatient services provided in the hospital setting.
The total amount you are being asked to pay for these services is $847.55.
You have been asked to pay these copays and coinsurance amounts for the outpatient services. 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 and coinsurance for the outpatient services provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203), tympanometry and reflex threshold measurements(92550), a comprehensive audiometry threshold evaluation and speech recognition (92557), and a comprehensive diagnostic evaluation (92588) to be rendered by the out of network (OON) provider.You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that your request is for services with an out of network provider. The services are not emergent/urgent innature and are available within the Plan's 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve an office visit (99203), tympanometry and reflex threshold measurements(92550), a comprehensive audiometry threshold evaluation and speech recognition (92557), and a comprehensive diagnostic evaluation (92588) to be rendered by the out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided on December 4, 2019.
You asked the Plan to pay for the dental services. You say that the services were part of your bi-yearly cleaning and yearly x-rays. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the limits set in your 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. Review of the file show that your $500 maximum was met on a previous claim. You reached the maximum on June 1, 2019 with the processing of the claim for services you received on May 29, 2019. Your EOC states, there is a $500 annual maximum (After the annual maximum is exhausted, any remaining charges are your responsibility). Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has been approved for a standard wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is a personal mobility deficit, but the documentation does not clearly reveal that this deficit impairs participating in MRADLs in the home. Furthermore, the documentation does not consistently reveal that you are unable to help this deficit with a quad cane. The 12/23/19 office visit notes that you can ambulate 50 feet in the house with a quad cane. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from June 26, 2019 to July 3, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from June 26, 2019 to July 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 17, 2019.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that this transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 the ambulance services. Our reviewer says that the ambulance services were not medically reasonable and necessary for the enrollee. The documentation does not support that other means of transport were contraindicated for this patient on this date of services. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The patient complained of nausea an no oral intake for one day. Vital signs were stable and there are no significant physical examination abnormalities. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the ambulance services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 16, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 16, 2019.