Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 11, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you paid the $35 copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on May 11, 2021. The total allowed amount is $2,208.00 and 20% of that is $441.60. You have been asked to pay the total coinsurance amount of $441.60 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part b prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve upgraded electronics. You say that you are requesting that a group 3 power tilt, power recline and power elevating leg rest be considered and approved. The Plan denied your request. The Plan says although there are 3 approved power options on this wheelchair, there is no medical need to control these power options through the joystick and the upgraded electronics are 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 pre-approve upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided did not sufficiently support that the requested upgraded electronics (expandable controller, expandable controller harness, electronic connection between wheelchair controller and two or more power seating system motors) were medically necessary, and the enrollee did not meet Medicare criteria for these. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve the surgical implant placements, custom fabricated abutments and abutment supported crowns.

You asked the Plan to pre-approve the surgical implant placements, custom fabricated abutments and abutment supported crowns. You say that the implants would help you chew food that you are unable to chew at this moment. You say that you want to replace your lower dentures with implants. The Plan denied your request. The Plan says the implants are not medically necessary. The Plan also says that since the implants are not covered, the abutments and crowns are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the surgical implant placements, custom fabricated abutments and abutment supported crowns when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgical implant placements, custom fabricated abutments and abutment supported crowns. Our physician reviewer found that teeth #17,18,19,20,28,29,30,31 and 32 are missing in the lower arch. Our reviewer says that as there are multiple missing lower teeth, and there was no prior failure of a full lower denture, there would be no medical necessity for the requested implant restorations under the plan provisions. Since the implants are not medical necessary, the abutments and crowns are also not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical implant placements, custom fabricated abutments and abutment supported crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placements, custom fabricated abutments and abutment supported crowns.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for surgical pathology services you received on August 3, 2021.

You asked the Plan to reduce the cost sharing for the surgical pathology services. You say that you should only have a $10 copayment, not 20% coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for diagnostic procedures and tests.

You have been asked to pay 20% coinsurance for the surgical pathology services. We looked at the actual procedure codes billed for these pathology services. The codes billed were 88305, 88344, 88342, and 88341. None of these procedure codes appear on the Medicare Clinical Lab Fee Schedule. Rather, these services are paid as physicians' service, not as lab services. That is why the surgical pathology services fall within the diagnostic procedures and tests benefit category instead of the lab 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 reduce the cost sharing for surgical pathology services you received on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, 81309, 81445) provided March 14, 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 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 codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, 81309, and 81445 are not supported in the medical record. Specifically, a required modifier was not billed to show an unbundled service. 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 (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, 81309, 81445) provided March 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan for a robotic total knee arthroplasty for the enrollee.

You asked the Plan to pre-approve the scan. You say that it is imperative for this to be done in order to perform surgery as planned. The Plan denied your request. The Plan says medical studies do not support the use of a CT scan to plan for this type of surgery, unless patient x-rays showed certain abnormal findings.

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 current evidence based medical literature does not support the routine use of computer-assisted navigated total knee arthroplasty over conventional total knee arthroplasty. This is due to the lack of large volume long term studies evidencing significantly different outcomes regarding pain and function with robot/navigated arthroplasty. In addition, there is limited published, large-scale, long-term peer-reviewed literature that shows the requested pre-operative CT scan to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for pre-operative CT scan for a robotic total knee arthroplasty is 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 the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan for a robotic total knee arthroplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for sleeve gastrectomy and an inpatient hospital stay.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service is available from a provider in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for sleeve gastrectomy and an inpatient hospital stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar, shower chair and non-skid shower mat.
You asked the Plan to pre-approve a grab bar, shower chair and non-skid shower mat. 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 grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar, shower chair and non-skid shower mat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurosurgery office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the neurosurgery office visit. You say that you believe this provider will give you the care you need. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the neurosurgery office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798) provided on October 5, 2020.
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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve spine surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested service is supported when you have had treatment that did not help.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. More conservative measures need to be tried and failed. Our physician reviewer found that the enrollee's condition does not meet criteria for these services. 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 pre-approve spine surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this treatment can be provided in network.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out of network physician services
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after October 15, 
2021 for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the member has been at the custodial level of care. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before October 15, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after October 15, 2021 for the 
enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T) and moderate sedation services.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the file does not show that you are enrolled in an approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is covered if you are enrolled in an approved clinical study. We looked at the file and Medicare rules. The file does not indicate you are enrolled in a clinical study. 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 pre-approve percutaneous image-guided lumbar decompression (0275T) and moderate sedation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) and diagnostic medial branch blocks (MBBs) at L3 and L4.
You asked the Plan to pre-approve the RFA and MBBs. You say that you would like reconsideration because the member has been treated in the past with steroid injections and RFA with good pain relief for about one year. The Plan denied your request. The Plan says the provider has not sufficiently excluded other sources of the member's pain.
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 RFA and MBBs. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The member also does not meet the LCD criteria for coverage. Our physician reviewer found the member needs new imaging and has sciatica. He also had surgery at the site of the proposed diagnostic MBBs. 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 RFA and MBBs have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) and diagnostic medial branch blocks (MBBs) at L3 and L4.