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

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen, pelvis, and chest for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor needs to cite sources to support their claim of medical necessity for this preoperative imaging to improve surgical outcomes.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the available records do not support that the enrollee's gastro-esophageal reflux disease (GERD) is medically refractory. There is no evidence that the hiatal hernia requires repair at this juncture. Relative to pre-operative imaging prior to bariatric surgery, the evidence-based standard of care guidelines recommend an abdominal ultrasound to assess the liver and gallbladder. The available record does not support a medically necessary exception for advanced imaging - e.g., specifically the CT scans as requested. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen, pelvis, and chest for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610) and the Hyaluronan or derivative, monovisc, for intra-articular injection, per dose (J7327) rendered by the out-of-network (OON) provider on July 23, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610) and the Hyaluronan or derivative, monovisc, for intra-articular injection, per dose (J7327) rendered by the out-of-network (OON) provider on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test 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 June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the clinical information provided supports the need for the requested services. You say that the treatment is considered safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. The Plan says that this treatment is not considered the standard of care.
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 Vertiflex Superion device. Our reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has mild-moderate spinal stenosis at multiple lumbar levels, and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of fusion at L3/4 and L5/S1, along with no discussion of spinal instability on flexion/extension films. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition.
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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on July 14, 2021.

You asked the Plan to pay for code 0013M. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for hearing aids provided on April 15, 2021.

You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan says you have already utilized the benefit of $1,600.00 for date of service December 20, 2018 and $100.00 for this date of service, April 15, 2021, meeting the $1,700.00 hearing aid total allowance every 3 years. The member is responsible for $2898.00.

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.

We looked at the file and the Plan's rules. The file shows that the Plan covered the hearing aid benefit of $1,600.00 on December 20, 2018, and the Plan covered the hearing aids provided on April 15, 2021 with a payment of $100.00, which met the $1,700.00 hearing aid maximum allowance. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the durable medical equipment provided on July 23, 2021.  You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing service (G0483) rendered by the out-of-network (OON) provider on May 11, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing service (G0483) rendered by the out-of-network (OON) provider on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on August 31, 2021.

You asked the Plan to pay for the bone replacement graft. You say that you were told the Plan would pay 50% of the cost, and you cannot afford it. The Plan denied your request. The Plan says this service is not a covered expense 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 for the bone replacement graft for ridge preservation (D7953) provided on August 31, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on April 14, 2021.  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 $90 copayment for each emergency care visit.   You have been asked to pay a $90 copayment for the emergency care visit 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 waive the copayment for the emergency room visit (99284) provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on October 8, 2021.  You asked the Plan to waive the copayment for the laryngoscopy. You say that the services should be covered as your bill was cheaper the last time you received these services. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $300 copayment for Outpatient hospital services.        You have been asked to pay a $300 copayment for a laryngoscopy. Laryngoscopy falls within the Outpatient hospital services benefit category. The record indicates that the previous services rendered on August 24th, 2021, were for a diagnostic exam, the copayment for October 8th, 2021, is higher because it is considered a surgical procedure. 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 laryngoscopy provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine provided on September 9, 2021.  You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on September 9, 2021.   Benefits for the shingles vaccine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room/urgent care visit provided July 31, 2021.  You asked the Plan to pay for the emergency visit. You say that you are appealing the denial of service. Since 1992 when you had the accident at work you had retired. You would like the Plan to cover since this is not correct. The Plan denied your request. The Plan says The Plan is secondary as this was a work-related injury and must be billed to the workers compensation insurance first.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary as this was a work related injury and must be billed to the workers compensation insurance first. As the secondary insurer, the Plan cannot be held responsible for the emergency visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency room/urgent care visit provided July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup (D2950) and crown (D2740) provided on September 16, 2021, and the recementing/rebonding of crown (D2920) provided on September 23, 2021.  You asked the Plan to pay for the dental services. You say that your provider told you that you would owe less for these services, and you say that you were supposed to only have a previous crown re-attached, not have a new one made. The Plan denied your request. The Plan says these services are not covered by your dental benefit.  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 for the core buildup (D2950) and crown (D2740) provided on September 16, 2021, and the recementing/rebonding of crown (D2920) provided on September 23, 2021.   Your complaint about potential misinformation from a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 had network providers available who could have provided 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 laboratory services provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $15 copayment charged for vision services provided on July 1, 2021.

You asked the Plan to waive these services. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment is a contractual obligation.

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 $15 copayment for routine eye exam.

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 $15 copayment charged for vision services provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide additional acupuncture visits.

You asked the Plan to provide additional acupuncture visits (97810). You say that acupuncture is really helping your lower back pain. The Plan denied your request. The Plan says you have exhausted your benefit.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you have already had 20 acupuncture visits this year. Therefore, we decided that the Plan does not have to provide additional acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician (CPT code 88141) provided on June 18, 2021.

You asked the Plan to pay for the service. You say that you did not have a "PAP" on the date of service that is documented on the statement. You state the exact date of service was June 11, 2021, not June 18, 2021. The Plan denied your request. The Plan says after confirmation with the provider's office on October 26, 2021, they confirmed that on June 11, 2021 you were seen in their office but advised that the pathology specimen was later sent on June 18, 2021, to the pathology lab, therefore, the pathology provider also billed the Plan for the service rendered. The Plan states they tried contacting you, numerous times to request the other insurance's Evidence of Benefit so the Plan can have the claim reprocessed.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has stated they need the other insurance's explanation of benefits. As the secondary insurer, the Plan cannot be held responsible for the service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician (CPT code 88141) provided on June 18, 2021.