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

We decided that the Plan does not have to waive the copayment for binocular microscopy provided on June 3,
2021, and July 8, 2021.
You asked the Plan to waive the copayment for binocular microscopy. You say that you feel that the procedure
should be included in the specialist copayment. 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 a $20
copayment for outpatient diagnostic procedures and tests.
You received binocular microscopy on June 3, 2021. Binocular microscopy is considered a diagnostic
procedure. Therefore, you are responsible to pay the $20 copayment.
You received binocular microscopy on July 8, 2021. Binocular microscopy is considered a diagnostic
procedure. Therefore, you are responsible to pay the $20 copayment. The total amount you owe is: $40.
You have been asked to pay the total copayment amount of $40 for binocular microscopy. Binocular
microscopy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 binocular microscopy provided on June 3, 2021, and July 8,
2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you would be safely and equally well served with skilled therapy services at an alternative level of care.

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.

The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure, chronic obstructive pulmonary disease exacerbation, pneumonia, and sepsis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the limited oral evaluation, intraoral x-ray and
endodontic therapy provided on April 19, 2021.
You asked the Plan to fully pay for the limited oral evaluation, intraoral x-ray and endodontic therapy. You say
that you were told the dentist was in-network and you would be covered 100%. You say that you would not
have borrowed the money if you knew you wouldn't be reimbursed. The Plan denied your request. The Plan
says the claim was processed as a one-time exception toward your in-network benefits.
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 Plan is only obligated to pay
$2,000 for your covered dental services every year. The Plan reprocessed the claim to pay $1,015 toward the
dental services received on April 19, 2021, to meet your $2,000 maximum. Therefore, we decided that the Plan
does not have to fully pay for the limited oral evaluation, intraoral x-ray and endodontic therapy provided on
April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) upper extremity (73200).

You asked the Plan to pre-approve the CT scan. You say that the CT scan for your foot was approved but not the forearm or elbow. You would like to appeal to get approval for this treatment. The Plan denied your request. The Plan says the clinical provided does not meet the medically necessary criteria.

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 CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee complained of right ankle pain. Tenderness was noted at the ankle. A CT of the forearm and elbow was requested. A CT was also requested for their foot which was approved. No PE findings were documented or symptoms reported regarding the upper extremities to justify CT of the elbow and forearm area. Therefore, based on the provided documentation, the CT upper extremity will be considered not 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) upper extremity (73200).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 24, 2021, through April 26, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you are not able to pay this amount. The Plan denied your request. The Plan says Medicare Part B does not cover self-administered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 self-administered drugs provided from April 24, 2021, through April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan (93880) provided on June 8, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that you should not have this copay because you had a similar service a few days earlier. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 each Medicare-covered standard x-ray and ultrasound. 

You have been asked to pay a $50 copayment for the duplex scan. The duplex scan you received is an ultrasound of both sides of the head and neck. 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 duplex scan (93880) provided on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you do not have the care you need at home. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2-surface resin-based composite on a posterior tooth
(D2392) for tooth #13 provided on March 1, 2021.

You asked the Plan to pay for the dental service. You say that you had not had fillings done in 30 years. You
say that you feel you are being discriminated against because of your age. You also say that if your tooth had
not been repaired, it would have become an interior cavity in the future. The Plan denied your request. The
Plan says resin-based composite is only covered for anterior, or front, teeth. The Plan also says that resin-based
composite for a posterior, or back, tooth is not listed as a covered service.

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 resin-based composite for a
posterior tooth is not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the 2-surface resin-based composite on a posterior tooth (D2392) for tooth #13 provided on
March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on May 27, 2021.

You asked the Plan to waive the copayment for an X-ray. You say that you thought that the X-ray would be
included in the follow-up appointment. 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 a $20
copayment for X-rays.

You received an X-ray on May 27, 2021. X-rays are not included in follow-up visits. Therefore, you are
responsible to pay the $20 copayment.

You have been asked to pay a $20 copayment for an X-ray. An X-ray falls within the outpatient hospital
services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for an X-ray provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0140, D7140, D7953) received on February 8, 2021.
You asked the Plan to pay for the services. You say that you were given incorrect information about this provider. The Plan denied your request. The Plan says the claim was processed appropriately, according to the benefits and the services rendered.
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 services when the services are medically necessary and reasonable.
A review of the case file shows that the calculation of $445.51 is correct for these services. There is a benefit maximum of $1000 for the billed dental services, and members are responsible for any amounts over this amount. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services (D0140, D7140, D7953) received on February 8, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says that coverage is not provided when the patient is
receiving re-treatment of knees previously treated with Zilretta.

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 Zilretta. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is a 79-yearold
male with right knee osteoarthritis with a history of Zilretta injections in the past. According to the
documentation, step therapy has been met. The provider is requesting an additional injection of Zilretta of the
right knee. Based on the drug Label, it does not preclude use of the drug more than one time. In addition, based
on the regulation 50.4.1 - Approved Use of Drug, Drugs or biologicals approved for marketing by the Food and
Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for
indications specified on the labeling.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve
Zilretta.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) electrical stimulation (97014)
mechanical traction (97012) ultrasound therapy (97035) provided April 3, 2020.
You asked the Plan to pay for the chiropractic services. You say that the plan has not paid your claims from
early 2020 based on another Plan showing up as primary. This is not true. Please resubmit the claims and pay
them. The Plan denied your request. The Plan says these services are not covered when rendered by a
chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for therapeutic exercises (97110) electrical stimulation (97014) mechanical
traction (97012) ultrasound therapy (97035) provided April 3, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional insertion of an anterior segment aqueous drainage device represented by current procedural terminology (CPT) code 0376T.

You asked the Plan to pre-approve CPT code 0376T. You say that the service in dispute is medically necessary. The Plan denied your request. The Plan says the service which remains in dispute is not a covered benefit because it is not a separately payable item, and the Plan has already approved another aqueous drainage device.

The Plan must follow Medicare rules. Medicare rules say that CPT Code 0376T for additional device insertions is not covered. Therefore, we decided that the Plan does not have to pre-approve additional insertion of an anterior segment aqueous drainage device represented by current procedural terminology (CPT) code 0376T.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records show you do not have a condition complex enough to require more than 25 days of continued acute inpatient hospital care with daily doctor visits and specialized nursing.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear to be improving gradually and should only require short-term additional acute care services that can safely be provided at the current facility. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided on July 25, 2019, by an out-of-network provider.
You asked the Plan to pay for the surgery services. You say that you had authorization for the services. The Plan denied your request. The Plan says there was no referral or 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 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 services at issue. There is no record of authorization in the case file. 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 surgery services provided on July 25, 2019, by an out-of-network provider.
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. The Plan denied your request. The Plan says you do not require an intensive multidisciplinary approach to daily therapy.

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 physician reviewer found that you were admitted to the acute care hospital for surgical management of a hip fracture after a fall. Your medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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 pay for the acupuncture treatment provided on January 27, 2021 to April 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture treatment. You say that you have been going to this provider for 12 years and you are requesting coverage The Plan denied your request. The Plan says If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
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 acupuncture treatment provided on January 27, 2021 to April 30, 2021 by an out-of-network (OON) provider.