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

We decided that the Plan has to pre-approveembryo transfer.You asked the Plan to pre-approvethe transfer. You say that this is medically necessary.The Plan denied your request. The Plan says that there is a lack of clinical information, and this service is not covered.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then thatitem 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 transfer. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is clinical information from a fertility specialist that was received regarding this request.The review has determined that the procedure should be considered medically reasonable and necessary. The embryo transfer procedure is the last one of the in vitro fertilization process. It is a critically important procedure. No matter how good the IVF laboratory culture environment is, the physician can ruin everything with a carelessly performed embryo transfer. The entire IVF cycle depends on delicate placement of the embryos at the proper location near the middle of the endometrial cavity -with minimal trauma and manipulation. For IVF, the woman is stimulated with injectable medications to develop multiple eggs. Eggs develop in follicles in the ovaries. When the follicles are mature, the egg retrieval procedure removes eggs from the ovaries. Sperm is added to the eggs and the next day we check the eggs for evidence of fertilization. An appropriate number of embryos are transferred to the uterus several days later -using ultrasound guidance for best placement.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transfer have been met.Therefore, we decided that the Plan has to pre-approveembryo transfer
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex Superiondevice placement surgery for the enrollee.You asked the Plan to pre-approvethese services. You say that the enrollee is a good candidate for this procedure.The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer is experimental. More research is needed to show safety and efficacy. There is no documented spinal instability. Hardware not needed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex Superion device placement surgery for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation (A0428, A0429) provided July 2, 2020, through August 5, 2020.
You asked the Plan to waive the copayment for ambulance transportation. You say that you cannot afford to pay the copayment. The Plan denied your request. The Plan says the copayment was 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 $350 copayment for ambulance services. You have been asked to pay a $350 copayment for ambulance transportation. The services at issue 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 transportation (A0428, A0429) provided July 2, 2020, through August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on September 8, 2020, through September 9, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you would like reconsideration because you did not know these drugs would not be covered.The Plan denied your request. The Plan says these services are non-covered based on Medicarerules and your Plan contract.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided on September 8, 2020, through September 9, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete lower denture rendered on September 10, 2020.You asked the Plan to pay forthese services. You say that you were advised that you had the same coverage as in 2015.The Plan denied your request. The Plan says the services are not 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe complete lower denture rendered on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe compression stockings with zippers (CPT Code A6549).You asked the Plan to pre-approvethe compression stockings. You say that you are using ace bandages that are old and have no compression to them.The Plan denied your request.The Plan says this item is not covered by Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the compression stockings have not been met. This item is not covered under Medicare. The rules say that the following are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): Gradientcompression stockings (CPT Code A6549).Therefore, we decided that the Plan does not have to pre-approvethe compression stockings with zippers (CPT Code A6549).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services provided to the enrollee on September 20, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the submitted documentation did not contain sufficient detail to support the billed charges.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 find that the denied code is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of outpatient rehabilitation setting (POS 31). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory services provided to the enrollee on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe chemotherapy services rendered on January 31, 2020.You asked the Plan to waive the coinsurance forthese services. You say that there should be no coinsurance.The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Part B covered chemotherapy drugs. Review of the file shows that you received chemotherapy services on January 31, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Part B covered chemotherapy 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 forthe chemotherapy services rendered on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating provider on January 10, 2020, to January 16, 2020.You asked the Plan to waive the coinsurance for injections. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.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% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total amount you are being asked to pay is $685.03. Injections fall within the Medicare Part B prescription drugs/in-network 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 injections provided by a participating provider on January 10, 2020, to January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services (V5260, V5267) purchased June 15, 2020 from an out-of-network (OON) provider.

You asked the Plan to pay for the hearing aid services. You say that you were unaware you would not be able to be reimbursed. The Plan denied your request. The Plan says there is no coverage when hearing aids are purchased from an OON provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from a contracted provider. 

We looked at this the file and the Plan's rules. The file indicates that you purchased the hearing aids from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid services (V5260, V5267) purchased June 15, 2020 from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenicular nerve radiofrequency ablation (RFA).You asked the Plan to pre-approvethe RFA. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this procedure is considered experimental/investigational and is the subject of on-going clinical trials.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 RFA have not been met.Therefore, we decided that the Plan does not have to pre-approvegenicular nerve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on March 6, 2020.You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $91.29. The total amount you are being asked to pay is $18.26 ($91.29 x 20% = $18.26). An injection falls 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 an injection provided by a participating provider on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on September 10, 2020.You asked the Plan to pay forthe scaling. You say that you feel the Plan should pay for this because it is the dentist's decision to make the decision whether a certain procedure is required or not.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you had gotten dentures about 6 to 7 years ago. You say that they are broken, they cut into your gums and cause you to bleed. You say that the dentures have been repaired 3 or 4 times. You also say that you did not receive dentures on February 13, 2019. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 frequency limit of once every 5 years has been reached. The record shows that the Plan paid for dentures that you received on February 13, 2019. Additionally, the provider confirmed that you received dentures on February 13, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveright carpal and ulnar release.You asked the Plan to pre-approveright carpal and ulnar release. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve right carpal and ulnar release. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent an injection to the cervical spine that reportedly resulted in numbness and tingling in the bilateral upper extremities. The enrollee then underwent C3-6 laminectomy and fusion surgery. The enrollee continues to complain of right upper extremity numbness and tingling. EMG/NCV testing revealed bilateral moderate carpal tunnelsyndrome. A review of the treatment records reveals no detailed evidence of a comprehensive and reasonable conservative treatment trial to the bilateral upper extremities prior to this request. Therefore, the enrollee does not meet criteria for the requested right carpal tunnel and ulnar release.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right carpal and ulnar release have not been met.Therefore, we decided that the Plan does not have to pre-approveright carpal and ulnar release.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee cannot be adequately care for in his current condition at a skilled nursing facility.The Plan denied your request. The Plan says the enrollee is stable for a safe transfer to a lower level of care.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care, suctioning, telemetry, surveillance laboratory studies, wound care, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care.There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 21, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says according to the Medicare Claims Processing Manual Chapter 34, a corrected claim must be received within one year (12 months) from the processed date of the original claim submission. The original claim has a processed date of August 2, 2019. The corrected claim was not received until August 31, 2020. This is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a valid claim for this service was not filed until August 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on June 16, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because
this service is covered by Medicare. The Plan denied your request. The Plan says Medicare does not cover
experimental services.
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 find that the Guardant360 testing is not supported in the record. Specifically, this service has not been
billed correctly. One unit of CPT code 81479 is used to report Guardant360 testing. Based on this information,
we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we
decided that the Plan does not have to pay for Guardant360 testing provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe visual field examination rendered on October 5, 2020.You asked the Plan to waive the copayment forthese services. You say that you had to have the testing separate from the office visit.The Plan denied your request. The Plan says the copayment was 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 $45 copayment for a medical eye exam. Review of the file shows that you received a visual field exam on October 5, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the medical eye exam 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 visual field examination rendered on October 5, 2020