Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the portable oxygen concentrator. You say that the additional oxygen system is required. The Plan denied your request. The Plan says the enrollee already has home oxygen equipment and has not provided documentation as to why duplicative equipment would be required.

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 portable oxygen concentrator. Our reviewer says that the service is not medically necessary. Our physician reviewer found no information on the specific indications has been provided despite multiple requests.

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 portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker provided on January 27, 2021.
You asked the Plan to pay for the walker. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the walker provided on January 27,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and the intraoral-complete series of radiographic images (D0210) provided June 21, 2021.
You asked the Plan to pay for the dental services. You say that you were not told that you could not have this service for 3 years and the dentist's office did not check to see if you were able to get these services. The Plan denied your request. The Plan says these services exceed the maximum frequency limitation.
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 approves coverage for D0150 and D0210 one procedure every 3 years. The records show that these services were provided on date of service April 12, 2019. 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 comprehensive oral exam (D0150) and the intraoral-complete series of radiographic images (D0210) provided June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Botox injections.

You asked the Plan to pre-approve Botox injections. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says off-label use of this drug for the member's condition is not medically accepted per Medicare rules and isn't covered based on available information.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Botox injections. Our reviewer says that there is no documentation that the requested use of Botox is Food and Drug Administration-approved for the enrollee's diagnosis. The use of Botox for cosmetic purposes for facial wrinkles is Food and Drug Administration-approved but it is not covered by Medicare as it is a cosmetic procedure. The use of Botox for cutis laxa senilis and scar conditions and fibrosis of skin is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found there is no documentation that the requested use of Botox meets Medicare criteria for safe and effective and otherwise 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Botox injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan (71260) provided February 11, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic radiology. 

You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the diagnostic radiology 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 a Computed Tomography (CT) scan (71260) provided February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) and visual field examination (92083) provided on May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that to your knowledge you are a participating office. Nothing on the enrollee's card indicates that this would require a prior authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 comprehensive eye exam (92014) and visual field examination (92083) provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient therapy visit provided on April 13, 2021.

You asked the Plan to waive the copayment for the outpatient therapy visit. The Plan denied your request. The Plan says the correct copayment was applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient mental health care. 

You have been asked to pay a $10 copayment for the outpatient therapy visit. The outpatient therapy visit falls within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient therapy visit provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85097, 88184, 88185, 88311, 88313, 88341, 88342) provided March 16, 2021.

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 the diagnosis code billed is for screening. Screening tests 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 tests at issue in this appeal were 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 lab services (85097, 88184, 88185, 88311, 88313, 88341, 88342) provided March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine, non-emergency transportation.
You asked the Plan to pre-approve routine, non-emergency transportation. You say that you do not have transportation after your colonoscopy and there is no taxi service on the island where you live. The Plan denied your request. The Plan says non-emergency transportation is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The file shows that your Plan does not provide coverage for a routine, non-emergency transportation benefit. Therefore, we decided that the Plan does not have to pre-approve routine, non-emergency transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that your father has mobility issues with difficulties bending and he is unstable. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for J. Jimenez, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to approve continued inpatient psychiatric services beginning September 23, 2021.

You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the you were involuntarily admitted to the hospital on September 15, 2021 with unspecified schizophrenia. Based on the records, it is not expected that you will improve in a reasonable period of time beyond the date in question, as you are not showing any dangerousness to self or others and no auditory or visual hallucinations. You have no aggressive behaviors. You are compliant with treatment and have no medication side effects. Continued services are not expected to improve your condition or for the purpose of diagnosis. It does not appear that active treatment is taking place. Continued inpatient psychiatric services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to approve continued inpatient psychiatric services beginning September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT colonography/virtual colonoscopy for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.

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 services. Our reviewer says that the
requested imaging is not medically reasonable or necessary. Our physician reviewer found the record indicates
that the ordered test is requested as an alternative to screening colonoscopy. 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve CT colonography/virtual colonoscopy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88305) provided on May 7, 2021.

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 the services were not pre-authorized or emergent.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (88305) provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine on May 13, 2021.
You asked the Plan to pay for the shingles vaccine. You say that the enrollee did not know this was covered. The Plan denied your request. The Plan says this is not a covered service per the Evidence of Coverage.
The Plan must follow Medicare rules. Medicare rules say that a shingles vaccine is not meet coverage rules and are therefore not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shingles vaccine have not been met. Therefore, we decided that the Plan does not have to pay for a shingles vaccine on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided March 31, 2021.

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 the documentation does not support the billed services.

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 G0482 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) 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 (G0482) provided March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services with dental code D4277.
You asked the Plan to pre-approve dental code D4277. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D4277 is not covered under the Plan's supplemental 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, dental code D4277 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental services with dental code D4277.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network services provided to the enrollee on May 27, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a referral from the primary care physician was not received.

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 out-of-network services provided to the enrollee on May 27, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for electrophoretic fractionation and quantitation serum (84165) provided
on April 28, 2021.
You asked the Plan to pay for electrophoretic fractionation and quantitation serum. You say that this was
medically necessary. The Plan denied your request. The Plan says that the billed modifier was invalid on the
date of service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has stated that the service at issue was billed with an invalid modifier.
While the records show that this service was billed with modifier 26, the Plan has not provided information or
documentation showing why this modifier was not valid. Therefore, we decided that the Plan has to pay for
electrophoretic fractionation and quantitation serum (84165) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is needed for the treatment of giant cell arteritis.
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 the services. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has giant cell arteritis. The record indicates that the intravenous form of the requested drug is prescribed. The Food and Drug Administration has not approved this formulation for the noted indication. The Medicare-approved drug compendia do not contain a supportive citation for the requested formulation for the enrollee's condition. The elements of the coverage rule 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K05530 provided
on March 17, 2021.

You asked the Plan to pay for supplies for a continuous glucose monitor. You say that the requested items are a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for
continuous glucose monitors and supplies have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assess
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
supplies for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not
have to pay for supplies for a continuous glucose monitor (K05530 provided on March 17, 2021.