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

 We decided that the Plan does not have to pre-approve Repatha.  You asked the Plan to pre-approve Repatha. You say that the medication is necessary. The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.  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 pre-approve Repatha.   Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 13, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal this service. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that you did not contact the Plan prior to this date of service to verify 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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on February 21, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network chiropractic services provided from May 12, 2021, to July 14, 2021.  You asked the Plan to pay for out of network providers. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  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 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. Therefore, we decided that the Plan does not have to pay for out of network chiropractic services provided from May 12, 2021, to July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2332) provided on August 19, 2021.  You asked the Plan to pay for the resin-based composite. You say that the cavity is covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that it was confirmed that you are not enrolled in the supplemental Dental Platinum Rider that would allow for additional coverage.  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 resin-based composite (D2332) provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from April 24, 2020, to February 24, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were never informed that you would owe anything and didn't receive a bill until a year later. 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 DME and related supplies.   You received DME and related supplies from April 24, 2020, to February 24, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service Service Allowed Amount Amount You Owe 4/24/2020 DME and Related Supplies $39.12 $7.81 5/24/2020 DME and Related Supplies $39.12 $7.81 6/24/2020 DME and Related Supplies $39.12 $7.81 7/24/2020 DME and Related Supplies $64.01 $12.79 8/24/2020 DME and Related Supplies $64.01 $12.79 9/24/2020 DME and Related Supplies $64.01 $12.79 1/24/2021 DME and Related Supplies $63.76 $12.74 2/24/2021 DME and Related Supplies $63.76 $12.74  The total amount you owe is: $87.28.   You have been asked to pay the total coinsurance amount of $87.28 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided from April 24, 2020, to February 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve an otolaryngology visit to be provided by an out-of-network (OON) provider at a tertiary care center.  You asked the Plan to pre-approve the out-of-network otolaryngology services. You say that the out-of-network services are medically necessary. The Plan denied your request. The Plan says that there are network providers available.  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 at issue in this case is not a network provider with the Plan. 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 out-of-network otolaryngology services. Our reviewer says that the out-of-network services are medically necessary. Our physician reviewer found the requested services for tertiary care center follow-up meet criteria for being medically reasonable and necessary. The patient has a difficult airway as evidenced by the laryngoscopic findings (left vocal fold paralysis, right vocal fold paresis, narrow airway) as well as the patient's past surgical and radiotherapy treatments of the neck due to thyroid cancer. Bilateral vocal fold paralysis is an uncommon condition with a high risk of mortality and severe impact on quality of life, and surgical treatments for this condition other than tracheostomy are complex.  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 out-of-network otolaryngology services have not been met.   The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the out-of-network otolaryngology services. Therefore, we decided that the Plan has to pre-approve an otolaryngology visit to be provided by an out-of-network (OON) provider at a tertiary care center.   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 the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that the enrollee has tried and failed conservative therapy, and this procedure is safe and effective. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence to determine if Intracept improves health outcomes.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to waive the copayment for the pulmonary function test provided on April 21, 2021.  You asked the Plan to waive the copayment for the pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the medical records. This means we are unable to determine if the copayment amount you are being asked to pay is correct. Therefore, we decided that the Plan has to waive the copayment for the pulmonary function test provided on April 21, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a provisional crown (D2799).  You asked the Plan to pre-approve a provisional crown. You say that you are very limited in what you can afford, and you cannot afford a temporary crown, but you need one before you can get the official crown for your mouth. You also say you would like to get an exemption in getting the temporary crown covered. The Plan denied your request. The Plan says the requested dental service is not covered under 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a provisional crown (D2799).
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve 3D radiographic procedures with computerized image post-processing for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the addition of 3D reformatting is standard in cases of total reverse shoulder arthroplasty and is used to precisely plan the device and approach to be used for the arthroplasty.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve 3D radiographic procedures with computerized image post-processing 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing visits in the home.  You asked the Plan to pre-approve the skilled nursing visits. You say that at this time registered nursing (RN) visits are urgently needed. The Plan denied your request. The Plan says the conditions needed to approve skilled nursing have not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 skilled nursing visits. Our reviewer says that the requested skilled nursing visits in the home are not shown to be medically necessary or reasonable. Our physician reviewer found no nursing or wound care records have been submitted for review. Our reviewer found that you are noted to have willing and available caregivers. Our physician reviewer also found that the documentation does not show that you have skilled nursing needs or that such needs are not being met by private caregivers.  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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits in the home.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0366) provided on August 26, 2021  You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you need the x-ray and anesthesia to be paid for. The Plan denied your request. The Plan says this service is not a covered benefit 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 cone beam computed tomography (CT) capture and interpretation (D0366) provided on August 26, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 1, 2021.  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.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left knee arthroscopy.  You asked the Plan to pre-approve a left knee arthroscopy. You say that the requested procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 a left knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 74-year-old female who is being treated for ankylosis, left knee. She underwent a left knee arthroplasty on August 11, 2020. She presented with pain and discomfort in the left knee. She still has quite a bit of stiffness in the leg. She finds difficulty primarily going down stairs and not so much going up. She did not get much past 95 degrees or so with flexion in physical therapy. Exam reveals minimal tenderness about the knee. She is able to obtain full extension and maintain straight leg raise.  She can flex her knee to just about 95 degrees, maybe a little further when provoked, but she does have quite a bit of stiffness noted thereafter. X-rays are noted to show well-positioned, well-placed prosthesis; near anatomic alignment, excellent bone cement mantle; patella seems to track fairly well within the midline.  However, she is far more than 3 months status post her left knee arthroplasty. There is limited published, large-scale, long-term peer-reviewed literature that shows arthroscopic treatment for post-operative stiffness to be an effective and/or safe treatment this far post operative. There is also greater than 90 degrees of knee flexion. 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 left knee arthroscopy 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 a left knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a left knee arthroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 2, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that it is very difficult for you to pay this bill with the lowest income that you have and going to see a specialist and pay $20.00 each time makes it even more difficult to pay this bill. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.  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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on June 28, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for pulmonary diagnostic testing provided on August 19, 2021.

You asked the Plan to waive the copayment for pulmonary diagnostic testing. You say that you did not receive any services on this date of service. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether or not you received pulmonary diagnostic testing. Therefore, we decided that the Plan has to waive the copayment for pulmonary diagnostic testing provided on August 19, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 26, 2021.

You asked the Plan to pay for the testing services. You say that the test was ordered to assist in determining optimal treatment options. The Plan denied your request. The Plan says the testing did not meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications.

We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the enrollee has decided to seek further cancer treatment or meets all of the indications for Larotrectinib. Furthermore, the file does not show that the testing was billed with the appropriate Current Procedural Terminology (CPT) code. 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 Guardant360 testing provided on July 26, 2021.