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

We decided that the Plan does not have to pay for the morphometric analysis (88361) provided on November 30, 2020.
You asked the Plan to pay for the services. 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the case file contains a WATS3D Test Requisition Form that indicates that the enrollee has a history of gastrectomy with Roux-en-Y for gastroparesis, and untreated non-diagnostic Barrett's esophagus. The case file also contains a WATS3D Histocytology Report. The case file does not include an endoscopy report or clinical records for this enrollee. The documentation does not support that the morphometric analysis, tumor immunohistochemistry, was medically reasonable and necessary for the enrollee in this case. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis (88361) provided on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure (LAAC) procedure.
You asked the Plan to pre-approve a LAAC procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the requested procedure have not been met because the enrollee is not enrolled in a clinical trial approved by Medicare.
The Plan must follow Medicare rules. Medicare rules say that LAAC is non-covered for the treatment of NVAF when not furnished under CED. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a LAAC procedure have not been met. Specifically, there is no indication in the case record that the enrollee is enrolled in a Medicare-approved clinical trial. Therefore, we decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure (LAAC) procedure
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy (10005)
provided on September 10, 2020.
You asked the Plan to waive the copayment for an outpatient procedure. You say that you received a bill six
months later for a biopsy. You also say that you have had a biopsy done in the past and you did not have to pay
$250. The Plan denied your request. The Plan says the copayment you are being charged is 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 a $250
copayment for services at an outpatient hospital facility.
You have been asked to pay a $250 copayment for an outpatient procedure. The records show that this
procedure was done at an outpatient hospital facility. The EOC confirms $250 is the required 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 a fine needle aspiration biopsy (10005)
provided on September 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental resin-based composites (D2392 and D2393), drugs
(D9630), and desensitizing medicaments (D9910) provided on January 20, 2021.
You asked the Plan to pay for dental services. You say that you had a bad tooth ache and had to have this done.
The Plan denied your request. The Plan says the denial of payment for these services is correct, because your
benefit for 1 dental filling per year was exhausted and the drugs and desensitizing medicaments are not covered
by the 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 benefit for dental resin-based
composite fillings for 2021 has been exhausted, and the dental drugs and medicaments are not covered by the
Plan's dental benefits. Therefore, we decided that the Plan does not have to pay for dental resin-based
composites (D2392 and D2393), drugs (D9630), and desensitizing medicaments (D9910) provided on January
20, 2021.
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the ambulance ride. We decided that the Plan does not
have to waive the cost share for the ambulance ride.

You asked the Plan to waive the cost share for the ambulance ride. You say that you thought the claim would
be paid at 100%. The Plan says that you have been asked to pay the correct cost sharing amount.

We decided that the Plan has to reduce the cost share for the ambulance ride.

The records show that the ambulance provider is out-of-network, therefore the out-of-network ambulance
service benefit applies.

The Plan says that you must pay a $300 copayment for the ambulance ride. Based on the plan contract,
however, you cannot be asked to pay more than 40% coinsurance for the out-of-network ambulance ride.
Therefore, we decided that the Plan has to reduce the copayment from a $300 copayment to $172.87
coinsurance.

We also decided that the Plan does not have to waive the cost share for the ambulance ride.

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 40% of
the allowed amount for the ambulance ride. The allowed amount is $432.18. ($432.18 x 40% = $172.87).
Therefore, we decided that the Plan does not have to waive the cost share for the ambulance ride.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy.
You asked the Plan to waive the copayment for physical therapy. You say that you are on SSA assistance and you are disabled and have no income and cannot afford the copayments for physical therapy visits. The Plan denied your request. The Plan says copayments are a fixed amount that the member is responsible for, and they cannot be waived or reduced.
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 $30 copayment for Outpatient rehabilitation services. You have been asked to pay $30 copayment for physical therapy. Physical therapy falls within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device (22867).

You asked the Plan to pre-approve the Coflex device. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Coflex device has not been shown to be helpful for the enrollee's condition.

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 Coflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental. More research is needed to show safety and efficacy.

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 Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device (22867).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety protocols (99072) provided January 4, 2021 to January 29, 2021.

You asked the Plan to pay for additional supplies and clinical staff time. You say that your physical therapist treated the enrollee in good faith and provided her with the medical care she required. Your office also provided transportation to allow the enrollee access to rehabilitative services. The Plan denied your request. The Plan says this service is bundled with the services provided to the enrollee on the same date of service and is not eligible for separate reimbursement.

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, we have confirmed that code additional supplies and clinical staff time has a bundled relationship with the services provided and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety protocols (99072) provided January 4, 2021 to January 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve high dose rate electronic brachytherapy.

You asked the Plan to pre-approve high dose rate electronic brachytherapy. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item 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 high dose rate electronic brachytherapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that radiation therapy, such as brachytherapy, may be an effective, nonsurgical option for primary cutaneous squamous cell carcinoma (cSCC) in select patients, specifically in older patients who are poor surgical candidates. This enrollee fits the criteria and the service is medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of high dose rate electronic brachytherapy have been met. Therefore, we decided that the Plan has to pre-approve high dose rate electronic brachytherapy.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine visit received on February 25, 2021.

You asked the Plan to pay for the periodic comprehensive preventive medicine visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received exceed your benefit limit.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. You had another periodic comprehensive preventive medicine visit on January 25, 2021 by a different provider. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine visit received on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services required exceeds the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says the enrollee has not completed the full course of care in the hospital.

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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for the coronavirus, complicated by fungemia and endocarditis. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

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-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says a physician order was
not submitted.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 for the drug testing services provided on February 8, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee's needs are being met in the current acute setting.

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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
complications related to prior bariatric surgery. The enrollee is not intubated/ventilated. There is no evidence
that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

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-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.

You asked the Plan to pre-approve twenty-four (24) additional routine transportation trips. You say that you
require transportation to your dialysis appointments. The Plan denied your request. The Plan says that your
request exceeds the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of twenty-four (24) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan does not have to provide routine transportation above the benefit maximum of twenty-four routine
transportation trips. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24)
additional routine transportation trips.
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 May 10, 2021.

You asked the Plan to pay for the dental service. You say that you changed dentists this year. You say that you do not remember when images were last done by your old dentist. You say that your new dentist took x-rays on your first visit with them. You also say that you would like this service to be covered. The Plan denied your request. The Plan says 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limit has 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 and complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on December 9, 2020, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable wheelchair with removable batteries to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. 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 a portable wheelchair with removable batteries to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.
You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.
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 ten (10) additional OT visits.
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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy of occupational 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. You have full strength, range of motion, and no contractures in the bilateral upper extremities. You are independent in eating and other activities of daily living are not being addressed in the treatment plan. You have had extensive education in exercises for the bilateral upper extremity. 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 your 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 ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits