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

We decided that the Plan does not have to pre-approve a panniculectomy.
You asked the Plan to pre-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. Medicare rules say that a panniculectomy is covered when specific
criteria are met.
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 services are not medically necessary. Our physician reviewer found the records show that the
panniculectomy is being requested for urinary incontinence. The record does not indicate that the enrollee has
intertrigo or interference with activities of daily living due to a pannus that extends below the pubic symphysis.
The record also suggests the procedure is requested for weight loss purposes. The criteria for coverage are not
met and the services are 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 pre-approve a panniculectomy
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).
You asked the Plan to pre-approve the knee orthosis. You say that the knee brace is medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered for enrollees that had
recent injury or surgery, or ambulatory enrollees who have documented knee instability.
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 knee orthosis. Our reviewer says
that the knee orthosis is not medically necessary. Our physician reviewer found the record does not show any
recent injury or surgery, and there is no documentation of knee instability on physical exam.
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 knee orthosis have not been met. Therefore, we decided that the Plan does
not have to pre-approve a knee orthosis (L1843).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular overdenture (D5865) or pay more for the complete maxillary denture (D5110) provided on August 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the mandibular overdenture and to pay more for the complete maxillary denture. You say that you spoke with a Plan representative regarding an in-network provider close to your home, and you were advised that this treating provider was in-network. The Plan denied your request. The Plan says the mandibular overdenture is not a covered benefit under your dental plan. The Plan also says that this claim processed correctly per your plan 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, mandibular overdenture (D5865) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for the complete maxillary denture (D5110), plus the difference between the billed amount and allowed amount for the service being received OON. The records also show that no incorrect information was provided to you by the Plan's customer service department. Therefore, we decided that the Plan does not have to pay for the mandibular overdenture (D5865) or pay more for the complete maxillary denture (D5110) provided on August 17, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 2-level lumbar transforaminal epidural injection.
You asked the Plan to pre-approve epidural injection services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says there is no documentation of radicular symptoms or plan to perform transforaminal epidural injections to the lumbar spine as required by Medicare rules.
The Plan follows Medicare rules. Medicare rules say that in order for epidural steroid injections to be covered, there must be evidence of radiculopathy. 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 epidural injection services. Our reviewer says that the requested epidural injections are not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has axial back pain from post laminectomy syndrome, facet loading and no radiculopathy. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 2-level lumbar transforaminal epidural injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy using the
ImpediMed L-Dex device.
You asked the Plan to pre-approve bioimpedance spectroscopy using the ImpediMed L-Dex device. You say that bioimpedance spectroscopy using the ImpediMed L-Dex device is medically necessary. The Plan denied your request. The Plan says bioimpedance spectroscopy using the ImpediMed L-Dex device is 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 bioimpedance spectroscopy using the ImpediMed L-Dex device. Our reviewer says that bioimpedance spectroscopy using the ImpediMed L-Dex device is not considered medically reasonable and necessary. Our physician reviewer found that you have a diagnosis of breast cancer and underwent left-sided lumpectomy and sentinel node biopsy. You are status post radiation therapy. Bioimpedance spectroscopy (BIS) is based on the theory that the level of opposition to flow of electric current (impedance) through the body is inversely proportional to the volume of fluid in the tissue. In lymphedema, with the accumulation of excess interstitial fluid, tissue impedance decreases. The literature
indicates that the clinical value and effectiveness of the requested bioimpedance spectroscopy using the ImpediMed L-Dex device in the setting of screening lymphedema in the absence of a complete axillary node dissection has not been demonstrated. The review has determined that the requested bioimpedance spectroscopy using the ImpediMed L-Dex device at issue in this case 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 bioimpedance spectroscopy using the ImpediMed L-Dex device have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy using the ImpediMed L-Dex device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided from July 14, 2020, to July 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the direct skilled nursing services of a RN. The Plan denied your request. The Plan says both the referring and attending providers are non-network providers with the enrollee's health plan. The Plan also says that
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 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 direct skilled nursing services of a registered nurse (RN) (G0299) provided from July 14, 2020, to July 27, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on July 1, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 93010 was billed with code 93458.We find that CPT code 93010 may be eligible for payment when billed with this code pair. The claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on July 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on August 4, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a routine screening and should be covered 100%. You stated that although two polyps were removed, this was not a diagnostic procedure. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they contacted the provider of this service, and they confirmed that this procedure was ordered and set up as a diagnostic procedure, not a screening procedure. That, in combination with the fact that there were polyps removed, makes this a diagnostic procedure.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery.
You have been asked to pay a $300 copayment for the diagnostic colonoscopy. The provider of this service confirmed that this service was ordered and performed as a diagnostic, not screening, procedure. You also had polyps removed during this procedure. Medicare considers colonoscopies with polyp removal to be diagnostic procedures. That is why the diagnostic colonoscopy falls within the outpatient surgery 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 the diagnostic colonoscopy you had at an outpatient hospital facility on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of current medical literature shows that this type of prosthesis for patients with upper extremity weakness from stroke, does not have proven benefit and is considered experimental/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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no consistent medical records provided are provided from the enrollee's treating provider documenting any specific upper extremity devices. There is no documentation as to why this device would be the best treatment option. An office visit note dated 10/11/2021 reports left upper extremity weakness but the neurologic physical examination is reported as "no gross neurologic deficits noted on brief screening exam."
Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance the contrast material provided on September 7, 2021.
You asked the Plan to waive the coinsurance the contrast material. You say that you are on a tight budget and
$16.80 is outrageous for iodine. You say that it would be cheaper at the store. The Plan denied your request.
The Plan says that the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan clearly says that enrollees pay $0 for medical supplies.
The Plan says you must pay 20% coinsurance for the contrast material. Based on the Plan contract, however,
you cannot be asked to pay more than $0 for the contrast material. The contrast material is considered a
medical supply. Therefore, we decided that the Plan has to waive the coinsurance the contrast material
provided on September 7, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee arthroscopy with meniscectomy.
You asked the Plan to pre-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. 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 services are not medically necessary. Our physician reviewer found the records show advanced knee
degenerative joint disease on imaging without significant loss of knee motion and locking. The records do not
support that the requested knee arthroscopy with meniscectomy is reasonable or medically necessary at this
time.
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 a knee arthroscopy with meniscectomy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedure for cholangiography (47531) provided on April 28, 2021.
You asked the Plan to pay for the injection procedure. You say that this date of service is unrelated to the enrollee's Hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the injection procedure for cholangiography (47531) provided on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that you have stabilized medically and are
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a
daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled
services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any
acute exacerbations of chronic medical problems. Your physical function is at or near his baseline and can
receive services 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems will be denied, as these
are emergency communications systems and do not serve a diagnostic or therapeutic purpose.
Medicare does not consider the requested Life Alert system to have a primarily medical purpose. Based on this
information, we decided that Medicare rules for coverage of the system have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Life Alert system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy visits provided on March 1, 2021, and March 5, 2021.
You asked the Plan to waive the copayment for physical therapy visits. You say that you were charged for 7 visits but only had 4 visits. You also say you do not believe services took place on the dates in question. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan contacted the provider to verify the services provided to you. The provider sent documentation to support that services were provided on the dates in question.
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 $40 copayment for each Medicare-covered physical therapy visit.
You have been asked to pay a sum of $80 in copayments for physical therapy visits ($40  2 visits = $80). Physical therapy falls within the Outpatient Rehabilitation 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 physical therapy visits provided on March 1, 2021, and March 5, 2021.
Your complaint about potential quality of service concerns is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints. The Plan indicated this grievance is being addressed in a separate case. Please contact the Plan for further information
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee