Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
April 4, 2021, to April 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe the
claim was denied because of the way that the doctor wrote up the claim. The Plan denied your request. The
Plan says this claim was not denied. Rather, the amount the enrollee is being billed represents his appropriate
cost sharing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $295 copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital
care.
Records show that the enrollee was in the hospital for 11 days. He was charged a $295 copayment per day for
each of the first 5 days, for a total of $1475. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
inpatient hospital services provided from April 4, 2021, to April 15, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trodelvy.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of
estrogen-receptor and progesterone-receptor positive breast cancer. Trodelvy is indicated in triple negative
breast cancer. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for
the enrollee's condition and the Medicare approved cancer drug compendia do not contain a supportive citation
for the use of the requested drug in the enrollee's clinical situation. Trodelvy is 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 Trodelvy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and three additional intraoral periapical x-rays (D0230 x3) provided on July 26, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were told you needed to have x-rays, or the doctor would not see you. You also say that you do not believe it is fair for this claim to be denied. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and three additional intraoral periapical x-rays (D0230 x3) provided on July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that it is medically necessary based on cerebral
infarction, unspecified. The Plan denied your request. The Plan says the clinical information provided does not
show the enrollee meets medical necessity criteria for a for seven (7) day SNF admission for this enrollee with
cerebral infarction.
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 the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a
practical matter, can be provided 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial doppler study of the intracranial arteries.
You asked the Plan to pre-approve transcranial doppler study of the intracranial arteries. The Plan denied your request. The Plan says a transcranial doppler study of the intracranial arteries 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 transcranial doppler study of the intracranial arteries. Our reviewer says that the requested transcranial doppler study of the intracranial arteries is not considered medically reasonable and necessary in this case.
Our physician reviewer found based on current guidelines, there would not appear to be any clinical indication for the performance of such imaging at this time. In summary, there is insufficient documentation to support the medical necessity for transcranial doppler examination of the intracranial arteries. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcranial doppler study of the intracranial arteries have not been met.
Therefore, we decided that the Plan does not have to pre-approve transcranial doppler study of the intracranial arteries.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (72100) provided on July 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72100
is a column II code to column I code 72083. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (72100) provided on July 19, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of oxygen chamber therapy provided by a chiropractor on June 23, 2021.

You asked the Plan to pay for the oxygen chamber therapy. You say that this should be covered since hyperbaric oxygen therapy is covered for wound healing, and the rendering provider is a licensed medical professional. The Plan denied your request. The Plan says Medicare does not cover this service from 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 the supervision of oxygen chamber therapy provided by a chiropractor on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until September 1, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the services provided on July 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says the requested procedure is supported for predominantly axial pain that is not
associated with radiculopathy or neurogenic claudication.
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 injections.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that in this case, the enrollee has radiculopathy. the requested procedure is
supported for predominantly axial pain that is not associated with radiculopathy or neurogenic claudication.
The clinical information provided does not meet this criterion and, therefore, the requested procedure is not
indicated 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 the injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) rendered on
July 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 71275 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. 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 pay for the computed
tomography angiography (CTA) rendered on July 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36000, 96372, 96374) provided on April 21,
2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are
bundled.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes
36000, 96372, and 96374, are column II codes to column I code 29130. This claim has not been billed with an
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the services (36000, 96372, 96374) provided
on April 21, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had at an outpatient hospital facility on April 28, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you have had other scans where you weren't charged, so you don't think this scan should be different. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for advanced imaging services at an outpatient hospital facility. You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the advanced imaging services at an outpatient hospital facility benefit category.
This copayment applies regardless of what you may have paid in the past. 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 computed tomography (CT) scan you had at an outpatient hospital facility on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup procedures (D2950) and second
porcelain/ceramic crown (D2740) provided on June 29, 2021.
You asked the Plan to pay for the core buildup procedures and second crown. You say that your dentist told
you that you were covered for two crowns per year. The Plan denied your request. The Plan says only one
crown procedure may be covered per year. You received two on the date in question; the first is covered, but
the second exceeds the frequency limitation for this service. A core buildup is not a covered service under your
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. The Plan does not cover
services that are not listed in the dental benefits chart.
The Plan can cover a maximum of one crown procedure per year.
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 or were provided in a frequency that exceeds what is covered by the
benefit. Documentation shows that you had two crowns provided on the date in question, and the Plan covered
one crown. Therefore, we decided that the Plan does not have to pay for the core buildup procedures (D2950)
and second porcelain/ceramic crown (D2740) provided on June 29, 2021.
Your complaint about potential misinformation provided by a Plan-contracted provider 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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) provided July 12, 2021.
You asked the Plan to pay for the crown. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750) provided July 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve the Synvisc. You say that Synvisc is medically necessary. The Plan denied your request. The Plan says Synvisc is not eligible for coverage under the Part B medical benefit when provided by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-strength lightweight manual wheelchair.
You asked the Plan to pre-approve the requested wheelchair. You say that walking is very painful. The Plan
denied your request. The Plan says there is no limitation that significantly impairs the enrollee's ability to
participate in mobility-related activities of daily living.
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain
medical indications.
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 requested wheelchair. Our physician
reviewer found that you have a medical history including chronic back pain with a lumbar radiculopathy. You
have had an acute exacerbation of chronic low back pain that started in September 2021. There is no
documented weakness, but using a walker makes the pain worse. In this case, the documentation does not
clearly indicate that you have a weakness or an inability to accomplish your mobility-related activities of daily
living. Therefore, the requested wheelchair is 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 requested wheelchair have not been met. Therefore, we decided that the
Plan does not have to pre-approve a high-strength lightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve power seat elevation feature. You say that you are appealing this denial. The
Plan denied your request. The Plan says the denial of authorization for this device is correct, because a power
seat elevation feature is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered.
We looked at the file and Medicare rules. The requested power seat elevation feature is not covered by
Medicare. Based on this information, we decided that Medicare rules for coverage of power seat elevation
feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat
elevation feature
Appeal type: Inpatient Hospital
Decision: Unfavorable

We 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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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. Our physician reviewer found the enrollee continues to require critical care services. The enrollee's acute care needs continue to be met in the current setting and the LTACH offers no services that are currently unavailable to the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight non-emergent ambulance transportation trips (A0428) to get to your scheduled doctor's appointments.

You asked the Plan to pre-approve non-emergent ambulance transportation. You say that these services are medically necessary for you to get to your life-saving appointments. The Plan denied your request. The Plan says ambulance services are not covered by Medicare or by the Plan when they are used to get to and from a physician's office.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.

The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve eight non-emergent ambulance transportation trips (A0428) to get to your scheduled doctor's appointments.