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

We decided that the Plan does not have to pre-approve Eysuvis drops.
You asked the Plan to pre-approve Eysuvis drops. You say that the enrollee has had diagnostic testing confirming dry eye diagnosis. You also say that the enrollee has had therapeutic failure of alternatives. The Plan denied your request. The Plan says outpatient prescription drugs are not covered under the enrollee's plan.
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 Eysuvis drops.
Benefits for Eysuvis drops 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for wound care. You say that you would like this reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 wound care provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for re-cement or re-bond a fixed partial denture (D6930)
provided on January 20, 2020.

You asked the Plan to pay for re-cement or re-bond a fixed partial denture. You say that you want the Plan to
reimburse you. The Plan denied your request. The Plan says the service at issue is not a covered 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.

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 re-cement
or re-bond a fixed partial denture (D6930) provided on January 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy you had at an ambulatory surgery center on April 28, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were told this procedure was covered 100%. You do not believe you should have a copayment just because two lesions were removed. 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 if you get a colonoscopy and any growths or lesions are removed, you are responsible for the copayment that applies for outpatient surgery. You contract says that you must pay a $225 copayment for outpatient surgery at an
ambulatory surgery center. Records show that you had lesions removed during your colonoscopy. According to your contract, if you have any growths removed during your colonoscopy, you pay the outpatient surgery copayment. You have been asked to pay a $225 outpatient surgery copayment for the colonoscopy. 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 colonoscopy you had at an ambulatory surgery center on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET scan with brain imaging for the enrollee.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the enrollee meets the criteria.
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the services. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found the notes provided for review only supported a diagnosis of dementia. The enrollee however did not meet diagnostic criteria for advanced dementia and frontotemporal dementia, as required by the NCD. In as much, this service would not Medicare criteria for coverage. 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 not been met. Therefore, we decided that the Plan does not have to pay for PET scan with brain imaging for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from January 25, 2020, through January 30, 2020 billed with principal diagnosis code A41.9.
You asked the Plan to pay for the inpatient services as billed. You say that the principal diagnosis is clearly documented throughout the record. The Plan denied your request. The Plan says that there is not sufficient objective documentation to support a diagnosis of sepsis.
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's review indicates that medical records were reviewed to decide whether diagnosis code A41.9 was supported. However, these medical records were not included in the file for independent review. Without the record upon which the Plan's denial was based, we find the denial of the billed Diagnosis Related Group (DRG) is not supported. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from January 25, 2020, through January 30, 2020 billed with principal diagnosis code A41.9.
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 pay for the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 4), and extractions (D7140 x 8) provided on April 20, 2021.
You asked the Plan to pay for the dental services. You say that the services you received were emergent. You say that all of your top teeth were infected. You say that the provider advised they accepted your insurance. You say that you live 8 miles from the states line. You also say that this was the closest provider to you. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that you were aware the office did not accept Medicare at the time the services were provided.
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, dental services performed out of network are not among those covered under this benefit. Additionally, the record shows that the Plan contacted the provider's office and the provider's office advised they told you that while they do participate with your dental plan, they do not participate with Medicare. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 4), and extractions (D7140 x 8) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services received on May 20, 2021.
You asked the Plan to pay for the services. You say that you paid out of pocket for these services and would like to reimbursed. The Plan denied your request. The Plan says this is an opt-out provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit services received on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the refill kit for implantable infusion pump provided on April
6, 2021.
You asked the Plan to pay for the refill kit for implantable infusion pump. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid.
In this case, the MUE for CPT code A4220 is 1. You billed 2 units of this code, exceeding the MUE. In
addition, code A4220 has a status indicator of "P" which means this service is always bundled into payment for
other services not specified and no separate payment is made. Based on this information, we decided that
Medicare rules for coverage of the refill kit for implantable infusion pump have not been met. Therefore, we
decided that the Plan does not have to pay for the refill kit for implantable infusion pump provided on April 6,
2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic fluid injection.
You asked the Plan to pre-approve amniotic fluid injection. You say that you are trying to avoid surgery and get pain relief. The Plan denied your request. The Plan says the requested 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 amniotic fluid injection. Our reviewer says that the documentation does not support that the requested amniotic fluid injection is medically reasonable or necessary. Our physician reviewer found you have a past medical history of arthritis and right knee pain. The medical records provided, and the Medicare-approved major drug compendia show there is no documentation that the amniotic fluid injection is medically reasonable and necessary for your knee arthritis pain as the treatment is considered experimental and investigational. Therefore, you do not meet criteria for the requested 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 amniotic fluid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic fluid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and periodontal maintenance (D4910) provided on April 28, 2021.
You asked the Plan to pay for a periodic oral evaluation, and periodontal maintenance. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and periodontal maintenance have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers
available to provide these services. 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 a periodic oral evaluation (D0120), and periodontal maintenance (D4910) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that the medication is necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve
Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466).
You asked the Plan to pre-approve a home mechanical ventilator. You say that this item 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. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
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 home mechanical ventilator. Our reviewer says that the requested home mechanical ventilator is not medically necessary and reasonable. Our physician reviewer found This patient has been given a diagnosis of COPD, although pulmonary function testing shows restrictive disease. The patient also has obesity hypoventilation syndrome (OHS). She has been on bilevel positive airway pressure (BiPAP) previously, with no evidence of BiPAP failure. The setting requested for the ventilator can be provided by BiPAP. Medicare does not cover a ventilator for OHS, or when used as BiPAP. 
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 home mechanical ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 9, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a nasopharyngoscopy.
You asked the Plan to pre-approve a nasopharyngoscopy. You say that it is necessary to address the causative factor, which is the dysfunction of the Eustachian tubes. You say that there is strong evidence that the requested intervention is beneficial both subjectively and objectively to patients. The Plan denied your request. The Plan says that the requested service is considered experimental and investigational.
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 a nasopharyngoscopy. Our reviewer says that a nasopharyngoscopy is considered medically reasonable and necessary in this case. Our physician reviewer found eustachian tube dilation is not experimental and can be beneficial for those who suffer from eustachian tube dysfunction. It has been determined that there is no scientifically proven way to medically treat eustachian tube dysfunction, but that it can be surgically managed. It was determined that a pressure equalizer tube is not a prerequisite for a dilation of the eustachian tubes. Our physician reviewer found that an audio showing negative pressure in the ears, effusion, or in this case, a tympanic membrane perforation, can help support the use of a dilation system. There can be long-term benefits to this procedure that is not experimental or investigational. 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 nasopharyngoscopy have been met. Therefore, we decided that the Plan has to pre-approve a nasopharyngoscopy.
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 pay for the limited oral evaluation, bitewing x-rays (D0270), and the periapical x-ray (D0220) provided on June 2, 2021.
You asked the Plan to pay for the dental services. You say that your filling fell out. You say that you needed to see a dentist immediately due to the size of the filling. You say that you were told the plan covers crowns, fillings, and bridges. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that limited oral evaluation and periapical x-ray are not listed as covered services.
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 and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on February 5, 2021. Additionally, the limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, bitewing x-rays (D0270), and the periapical x-ray (D0220) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient physician services provided on May 14, 2021, reported with primary diagnosis code F05.
You asked the Plan to pay for the inpatient services as billed. You say that the diagnoses are supported by the record, and payment should be made. The Plan denied your request. The Plan says the primary diagnosis code is a manifestation code and should not be used as primary.
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes are manifestation codes and should not be reported before the code which reports the etiology. In this case, code F05 (Delirium due to known physiological condition) has a note which indicates to Code First the underlying physiological condition. as such this should not be used as the primary diagnosis. Therefore, we decided that the Plan does not have to pay for the inpatient physician services provided on May 14, 2021, reported with primary diagnosis code F05.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on April 20, 2021.
You asked the Plan to reduce the copayment for the ultrasound. You say that you have always paid a $40 copayment for ultrasounds. You say you did not have the ultrasound done at the hospital. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $100 copayment for diagnostic procedures and tests at an in-network outpatient hospital.
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital which is the parent location. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the ultrasound provided on April 20, 2021.