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

We decided that the Plan does not have to pre-approve an ultrasound, transplanted kidney (76776), positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan; skull base to mid-thigh (78815), CT scan of the soft tissue neck (70490), CT scan of the thorax (71250), and CT scan of the abdomen and pelvis (74176).
You asked the Plan to pre-approve an ultrasound, PET CT scan; skull base to mid-thigh, CT scan of the soft tissue neck, CT scan of the thorax, and CT scan of the abdomen and pelvis. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 an ultrasound, PET CT scan; skull base to mid-thigh, CT scan of the soft tissue neck, CT scan of the thorax, and CT scan of the abdomen and pelvis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the notes indicate a knowledge by attending physicians that a battery of imaging studies needs to be performed. It seems the argument is related to which facility and to what extent or type of studies need to be done. In order to organize care and not produce more fragmentation it is very reasonable for the facility where a second transplant is likely to be done provides the imaging studies deemed appropriate by the transplant surgeon and committee. Clearly both Medical Centers are both excellent state of the art facilities and can offer any of the requested imaging studies which the transplant team deems appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound, PET CT scan; skull base to mid-thigh, CT scan of the soft tissue neck, CT scan of the thorax, and CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasound, transplanted kidney (76776), positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan; skull base to mid-thigh(78815), CT scan of the soft tissue neck (70490), CT scan of the thorax (71250), and CT scan of the abdomen and pelvis (74176).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by out of network (OON) provider.
You asked the Plan to pre-approve the OON ophthalmology services. You say that you have seen three eye doctors and continue to have issues with your vision and feel that you are at risk of losing vision in this eye. You feel that a second opinion is necessary. The Plan denied your request. The Plan says the plan's network has a glaucoma specialist. She specializes in surgical treatments for advanced glaucoma. Since the network has a subspecialist with expertise in your condition, there is no need for an OON referral at this time.
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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the ophthalmology services to be provided by out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an MRI provided at the facility on September 26, 2019.
You asked the Plan to waive the coinsurance for an MRI. You say that you disagree with the additional 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 20% coinsurance up to a maximum of $75 per day for MRI's. You received an MRI on September 26, 2019. The allowed amount is $307.80 and 20% of that is $61.56. You have been asked to pay the coinsurance amount of $61.56 for an MRI. An MRI 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 coinsurance for an MRI provided at the facility on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of
network provider.
You asked the Plan to pay for outpatient therapy. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the member's primary care physician did
not refer the member to the Hospital. The Plan says that no prior authorization was made for
these services.
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 medical services provided on July 31, 2019 by
out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint.
You asked the Plan to pre-approve an arthrodesis of the sacroiliac joint. You say that the pain you are in has a
negative impact on your quality of life. You say that the requested procedure has numerous positive reports
from patients and state of the art spinal specialists. You say that you have been seen at the Institute for 9 years and that you don't want to go elsewhere because of the previous excellent post-op results
from that facility. The Plan denied your request. The Plan says they do not see a dedicated MRI of the SI joint that excludes the presence of destructive lesions or inflammatory arthropathy. The Plan says that they do not
see documentation that there has been at least 75% reduction of pain for the expected duration of the anesthetic
used following an image-guide, contrast enhanced SIJ injection on 2 separate occasions. The Plan says that the
documentation provided does not support Medicare criteria have been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that experimental and investigational devices 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 an arthrodesis of the sacroiliac joint.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found there is no documented SI join instability, fracture, or tumor. An SI
joint fusion for degenerative back pain is considered experimental and investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an arthrodesis of the sacroiliac joint have not been met. Therefore, we decided
that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve this drug. You say that Repatha is indicated to reduce the risk of myocardial infraction, stroke, and coronary revascularization in patients with established cardiovascular disease. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Repatha for the enrollee.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a self-releasing roll belt.
You asked the Plan to pre-approve a self-releasing roll belt. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a self-releasing roll belt.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2019 through July 25, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. The enrollee had stable vital signs and no advanced care orders. Inpatient care services were not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.
Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2019 through July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Diagnostic Corneal Topography (92025) provided December 26, 2019.You asked the Plan to pay for the Diagnostic Corneal Topography. You say that the service was medically necessary.The Plan denied your request. The Plan says the use of this procedure for this diagnosis is experimental and not covered.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 Diagnostic Corneal Topography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient's examination findings, and diagnosis of cataract and glaucoma did not warrant testing with corneal topography. It is not the standard of care for cataract evaluation or glaucoma diagnosis and 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 the Diagnostic Corneal Topography have not been met.Therefore, we decided that the Plan does not have to pay for Diagnostic Corneal Topography (92025) provided December 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the CT Scan of the abdomen and pelvis (74178) provided on October 24, 2019.You asked the Plan to adjust the copayment for this service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment was 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 $150 copayment for each Medicare-covered radiological diagnostic service. You have been asked to paya $150 copayment for the radiological diagnostic service provided. 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 adjust the copayment for the CT Scan of the abdomen and pelvis (74178) provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast procedure (19499) provided on July 3, 2019.You asked the Plan to pay forthe breast procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed.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 19499 is unlisted procedure, breast.We asked our coder to carefully review the case file andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the breast procedure. Our reviewer says that CPT code 19499 does not meet criteria for billing or reimbursement consideration. Our coder found the operative note describes reconstruction of the breast (19366), angiography of the flaps (15860) and nipple reconstruction (19350, not billed). There is no evidence that a separate and distinct breast procedure was performed.We looked at this coder 's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the breast procedure have not been met. Therefore, we decided that the Plan does not have to pay for a breast procedure (19499) provided on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you cannot walk well and your doctor recommended orthotics to help your feet and balance.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these services. 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator (E0747). You asked the Plan to pre-approve the osteogenesis stimulatory. You say that you feel that the service should be covered because you have two broken bones in your foot and you had an MRI and they have not healed yet.The Plan denied your request. The Plan says medical necessity has not been established. It has been less than 3 months since the injury and no radiographic support of non-union.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria not met for bone growth stimulator. More time is needed to establish the diagnosis on nonunion.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 osteogenesis stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve osteogenesis stimulator (E0747).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveOrthovisc.You asked the Plan to pre-approveOrthovisc. The Plan denied your request. The Plan says that the use of this medicine is not helpful in treating knee pain.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 Orthovisc. Our physician reviewer found that you are not a candidate for non-steroidal anti-inflammatory drugs, and have not responded to conservative therapy. You have had symptomatic improvement with the use of a series of 3 Orthovisc injections in the past. Orthovisc is FDA approved to relieve knee pain due to osteoarthritis, so it is safe and effective. Additionally, based on the available documentation, Orthovisc is medically reasonable and necessary to treat your osteoarthritis pain.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have been met.Therefore, we decided that the Plan has to pre-approveOrthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe crown (D2750) for tooth #3.You asked the Plan to pre-approvethe crown for tooth #3. The Plan denied your request. The Plan says tooth #3 does not have pathologic destruction by caries or trauma involving three or more surfaces and at least one cusp. The Plan also says that the service is not reasonable or necessary.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 for tooth #3 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 for tooth #3. Our reviewer says that the crown for tooth #3 is not medically necessary. Our physician reviewer found tooth #3 does not appear to have significant coronal breakdown to warrant the placement of a crown restoration (D2750). Our reviewer also found that there is no indication in the record of recurrent caries or fracture. We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that the Plan's rules for coverage of the crown for tooth #3 have not been met.Therefore, we decided that the Plan does not have to pre-approvethe crown (D2750) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses (V2781, V2025) provided January 23, 2020.You asked the Plan to pay forthe eyeglasses. You say that the eyeglasses should be covered.The Plandenied your request. The Plan says vision services are not covered when received out-of-network.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from in-network providers.We looked at the file and the Plan's rules. The eyeglasses were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay foreyeglasses (V2781, V2025) provided January 23, 2020.