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

We decided that the Plan does not have to pre-approve HFE (hemochromatosis) (hereditary hemochrosis) gene analysis (81256).
You asked the Plan to pre-approve HFE gene analysis. You say that you are very concerned for the enrollee's health. The Plan denied your request. The Plan says the requirements for coverage of this testing have not been met.
The Plan must follow Medicare rules. Medicare rules say that HFE gene analysis is considered medically necessary in patients with iron overload of uncertain etiology when the test is used to avoid liver biopsy in someone when the ferritin and the transferrin saturation are elevated greater than 45%. We looked at the file and Medicare rules. The record shows that the enrollee's the transferrin saturation is 31%. Based on this information, we decided that Medicare rules for coverage of HFE gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve HFE (hemochromatosis) (hereditary hemochrosis) gene analysis (81256).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. You say that the enrollee is still a danger to self. The Plan denied your request. The Plan says the enrollee does not have acute symptoms that require inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond July 17, 2021, were requested. 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 continued services. Our physician reviewer found that it was not expected that this enrollee would improve in a reasonable period of time. She did not have suicidal or homicidal ideation noted. She denied any auditory or visual hallucinations.
She was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that the records provided support the need for physical therapy services. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee's functional skills were reviewed with all staff/team members. The enrollee has staff support. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 24, 2021.
You asked the Plan to pay for the dental service. You say that the dentist did not disclose the fact that he was doing a set of x-rays that would not be covered by your plan. You also say that this service should be covered. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided January 16, 2021.
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
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 CPT code 99291 is not supported in the medical record. Specifically, the diagnosis code billed requires that the underlying condition be coded first. An additional code should be reported for this diagnosis. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic visits (98941) provided February 25, 2021 to March 12, 2021.

You asked the Plan to waive the copayments for the chiropractic visits. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 copayment for chiropractic services. 

You have been asked to pay $120 for 6 chiropractic visits ($20 per visit). The chiropractic visits fall within the chiropractic 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 chiropractic visits (98941) provided February 25, 2021 to March 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided February 3, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided February 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy visits provided from
September 30, 2020, to November 30, 2020.
You asked the Plan to waive the copayment for radiation therapy. You say that you were not aware that you
were expected to make a $45 copayment for each visit, and do not believe you should be charged this amount.
The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $45
copayment for each radiation therapy visit.
There were 40 visits, resulting in a total copayment amount of $1,800.
You have been asked to pay $45 copayment for radiation therapy. Radiation therapy falls within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for radiation therapy visits provided from September 30, 2020, to November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a removal of lateral exostosis (D7471), removal of torus mandibularis (D7473), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and each additional 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9243) provided on January 13, 2021.
You asked the Plan to pay for the removal of lateral exostosis, removal of torus mandibularis, and intravenous moderate (conscious) sedation/analgesia. You say that you would like these services covered. The Plan denied your request. The Plan says these services are dental in nature and are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for a removal of lateral exostosis (D7471), removal of torus mandibularis (D7473), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and each additional 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9243) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test (86592) provided on October 8, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $4.27 copayment for the diagnostic laboratory test provided. This is the Plan's allowed amount which is less than the applicable copayment for this service. 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 the laboratory test (86592) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 30, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lutathera (A9513).

You asked the Plan to pre-approve Lutathera, Lutetium lu 177, dotatate, therapeutic, 1 millicurie (A9513). You say that you want to continue this therapy as planned to maximize the enrollee's progression free survival. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and isn't covered based on available information.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Lutathera, Lutetium lu 177, dotatate, therapeutic, 1 millicurie (A9513). Our reviewer says that the requested use of Lutathera is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lutathera, Lutetium lu 177, dotatate, therapeutic, 1 millicurie (A9513) have not been met. Therefore, we decided that the Plan does not have to pre-approve Lutathera (A9513).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visit and injection services provided January 12, 2021.

You asked the Plan to waive the copayment for office visit and injection services. You say that you believe that since you never had a provider visit, this copayment should be waived. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 specialist physician services. 

You have been asked to pay a $40 copayment for office visit and injection services. This service falls within the specialist physician 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 office visit and injection services provided January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone Tab.

You asked the Plan to pre-approve Eszopiclone Tab. You say that the enroll is stable on the prescribed drug and the change in the drug regimen is expected to be ineffective or cause harm to the enrollee. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.

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 pre-approve Eszopiclone Tab.

Benefits for Eszopiclone Tab 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial at this point and, as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns.
You asked the Plan to pre-approve dental crowns. You say that your tooth has trauma. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because your tooth does not appear to have significant breakdown.
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 dental crowns 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 dental crowns. Our reviewer says that you do not meet the Medicare criteria for the requested dental crowns. Our physician reviewer found your tooth #7 appears to have an existing moderate sized restoration that encompasses about 30% of the tooth structure. The incisal edges are not involved. In general, a crown is considered when more than 50% of the tooth structure has been damaged from fracture or decay. In this instance the existing filling is of moderate size but does not significantly weaken the tooth structure. There is no indication that your tooth has received endodontic treatment. A final radiograph of the completed endodontic fill would be required for approval of a crown, with the need for a crown determined based on this. There is insufficient missing structure to meet the criteria for a 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 dental crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve dental crowns.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate biopsy provided on March 5, 2021.
You asked the Plan to pay for the biopsy. 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 pay for the biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that transperineal stereotactic template guided saturation biopsy of the prostate is indicated in men with two prior negative prostate biopsies and a prostate specific antigen (PSA) that is persistently rising. The medical records provided indicate that this enrollee has not a prior prostate biopsy. 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 biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the prostate biopsy provided on March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.

You asked the Plan to pre-approve the proton beam therapy. You say that the documentation provided supports the need for proton beam therapy. The Plan denied your request. The Plan says evidence for treatment of prostate cancer with proton radiation is conflicting and poor.

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 proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiotherapy (IMRT) and image-guided radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.

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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on November 18, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes are bundled into codes paid on the same claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
The file shows that codes 43753, 93010, and 99292 were billed for services on the date at issue in this case. We find that the CPT codes are Column Two codes. The claim does not show the codes were billed with modifiers valid for separate payment. 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 critical care services provided on November 18, 2020.