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

We decided that the Plan does not have to waive the copayment for ambulance services you received on April
23, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be
waived since this service was needed due to breathing problems from COVID-19. The Plan denied your
request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment per trip for ambulance services.
You have been asked to pay a $250 copayment per trip for the ambulance services. According to the Plan's
website, if you get sick with COVID-19, you will be responsible for any of your regular cost sharing. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for ambulance services you received on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured
pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not
covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our reviewer says that
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the record does
not indicate that the enrollee has a covered condition as enumerated in the coverage criteria. Notwithstanding
that fact, the provided records indicate that the enrollee is being treated with BiPAP. The provided primary
source documentation does not contain sufficient detailed information in the medical record to justify the
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has
indicated such a device is available. The elements of the coverage criteria are not satisfied.
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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jevtana.

You asked the Plan to pre-approve Jevtana. The Plan denied your request. The Plan says the use of this drug requires failure of a prior docetaxel-containing regimen.

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 Jevtana. Our physician reviewer found that the enrollee has a diagnosis of castration resistant metastatic prostate cancer. The requested use of Jevtana is not FDA approved for the enrollee's diagnosis. He has not yet received docetaxel chemotherapy. The requested use is only supported as a phase II trial by the major drug compendia. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Jevtana have not been met. Therefore, we decided that the Plan does not have to pre-approve Jevtana.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87150) provided August 29, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 87150 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87150) provided August 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan has to waive the copayment for an office visit provided on June 4, 2021.
You asked the Plan to waive the copayment for an office visit. You say that your card says that you should not be billed for services. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for physician/practitioner services, including doctor's office visits. The Plan says you must pay $94.74 for an office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an office visit. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on June 4, 2021.
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 pre-approve lumbar facet joint block.

You asked the Plan to pre-approve lumbar facet joint block. You say that this procedure is medically
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been
met.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are limited to one spinal
region per session.

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 lumbar facet joint block. Our reviewer
says that the requested services are not medically reasonable and necessary. Our physician reviewer found this
specific request is to perform Lumbar medial branch blocks (MBBs) at the same time as thoracic MBBs. The
LCD limits the blocks to one spinal region per session. Therefore, the request to perform additional MBBs in a
different region is deemed not medically reasonable or 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 lumbar facet joint block have not been met. Therefore, we decided that the Plan
does not have to pre-approve lumbar facet joint block.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in your home.
You asked the Plan to pre-approve the PT visits. You say that you need these services. The Plan denied your request. The Plan says the PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 PT visits. Our reviewer says that the physical therapy visits are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has documented, ongoing, home health physical therapy needs. The reviewer found that the enrollee appears to have reached a plateau in function. Therefore, the reviewer found that the requested physical therapy visits are not medically necessary or reasonable. 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 PT visits have not been met. Specifically, the file shows that the enrollee's function has plateaued. Therefore, we decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in your home.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the clindamycin phosphate injection (S0077) provided on billed on the claim for March 2, 2020, through March 17, 2020.
You asked the Plan to pay for the clindamycin phosphate injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S0077 is not payable by Medicare.
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 S0077 is not supported in the record. Specifically, CPT code S0077 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the clindamycin phosphate injection have not been met. Therefore, we decided that the Plan does not have to pay for the clindamycin phosphate injection (S0077) provided on billed on the claim for March 2, 2020, through March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laser therapy services (procedure code 97039) provided to the enrollee on April 13, 2021.
You asked the Plan to pay for the services. You say that a representative gave you the indication that this would be reimbursed. The Plan denied your request. The Plan says there is a more appropriate code for this service, which is excluded by Medicare.
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 97039 is "Unlisted modality (specify type and time if constant attendance)." We find that CPT code 97039 is not supported in the medical record. Specifically, a more specific code is appropriate to use in this case for laser therapy.
The appropriate code would be S8948 (Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes), which is not paid by Medicare. 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 laser therapy services (procedure code 97039) provided to the enrollee on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).

You asked the Plan to pay for the services. You say that you are not contracted with the facility or the prescribing physician, and do not receive payment from either provider. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement. 

The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0673, E0675).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the Plan denied your request. The Plan says this
is considered experimental and investigational.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found these devices remain experimental for use in spinal surgery. 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-rays provided on June 7, 2021.
You asked the Plan to pay for the additional intraoral x-rays. You say that the provider did not apply the $74.39 plan discount, so you overpaid. You say that the out-of-pocket cost for your first visit was only supposed to be $40. The Plan denied your request. The Plan says only one intraoral x-ray is covered per calendar year.
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, you also have a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 7, 2021, which exhausted your benefit. You are responsible for the remaining cost of $40 for the two denied intraoral x-rays. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-rays provided on June 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the aspirin, 3-24 mg tablets, provided in an outpatient setting
on June 27, 2021. You asked the Plan to pay for the self-administered drug. You say that you were not able to get your blood
pressure down. You say that you took your medication that morning and half of an aspirin. You say that they
had difficulty in the emergency room. You also say that they gave you 3 baby aspirin. The Plan denied your
request. The Plan says the drug you received is considered self-administered. The Plan says self-administered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is
not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the aspirin, 3-24 mg tablets,
provided in an outpatient setting on June 27, 2021.
Benefits for the self-administered 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided May 4, 2021.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied
your request. The Plan says the claim cannot be paid as 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.
We find that CPT code 71045 is not supported in the medical record. Specifically, the claim was billed with an
outpatient place of service, however records show the patient was an inpatient when the services were
provided. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been
met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that these services with an OON provider you have seen previously continue to be medically necessary. The Plan denied your request. The Plan says there are in-network providers available for your medical needs.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.
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 office visit. Our reviewer says that an office visit to be provided by an out-of-network (OON) provider is not medically reasonable and necessary. Our physician reviewer found you had your first visit evaluation with the OON provider August 5, 2021. The results indicated that the member has advanced Parkinson's Disease stage 3 since 2011, is not a good candidate for deep brain stimulation, and has severe dyskinesia. The recommendation was to continue Levodopa, start DUOPA since not a candidate for deep brain stimulation, and home health services. You were seen by the OON provider one time over 90 days ago for a second opinion and possible deep brain stimulation, which was not recommended. The review has determined that it is not medically reasonable or necessary for the enrollee to see the OON provider over the Plan's in-network options. 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 office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided July 6, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you should not have to pay for the services. The Plan denied your request. The Plan says you have exceeded the frequency limit for intraoral x-rays.
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 one intraoral x-ray per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray was covered on July 6, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health services provided from June 1, 2021, to June 13, 2021.

You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient mental health services. Our reviewer says that the inpatient mental health services were not medically necessary. Our physician reviewer found the records provided did not indicate that it was expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. 

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 inpatient mental health services have not been met. Specifically, the file shows that the enrollee was not a danger to themself or others. Therefore, we decided that the Plan does not have to pay for the inpatient mental health services provided from June 1, 2021, to June 13, 2021.