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

 We decided that the Plan has to pre-approve cervical epidural steroid injections.  You asked the Plan to pre-approve cervical epidural steroid injections. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that there is no evidence that injections will be done using computed tomography (CT) guidance.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are subject to the criteria listed in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve cervical epidural steroid injections. Our reviewer says that the requested injection services are medically reasonable and necessary. Our physician reviewer found the enrollee has chronic neck pain with radicular symptoms. She takes Gabapentin, Tylenol, Tramadol and Cyclobenzaprine for pain. The magnetic resonance imaging (MRI) scan shows multi-level degenerative changes with disc herniations at C3-C4, C4-C5 with spinal stenosis. The patient had a cervical epidural steroid injection with 90% pain relief for 3-4 months. The request is for repeat ESI with Fluoroscopy. The patient has met all of the criteria of the LCD. Although the Plan has denied coverage based on a lack of CT guidance, there is no evidence to support this. The request is medically reasonable and 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 cervical epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve cervical epidural steroid injections.   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 eyeglass frames (V2020) purchased on July 13, 2021.
You asked the Plan to pay for the frames. You say that this provider was close by, and these services were
necessary. The Plan denied your request. The Plan says routine eyewear is not covered by your benefit
package. The base supplemental vision benefit includes only an annual eye exam, and you did not opt to
purchase the additional optional supplemental vision benefit in 2021.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan's routine vision benefit covers one routine eye exam per year. Additional vision benefits are
available for an extra premium.
We looked at the file and the Plan's rules. The record indicates that you did opt for one of the Plan's additional
benefit packages, but you did not choose the vision benefit package. While the Plan does offer some vision
services in excess of Medicare covered, routine eyewear is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the eyeglass frames (V2020) purchased on July
13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2020.
You asked the Plan to pay for the medical services. You say that you paid the amount of $899 for ambulance transportation without knowing it is a service covered by your plan. The Plan denied your request. The Plan says there was no itemized bill, medical records, or documentation to support proof and payment of the services rendered.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The documentation submitted did not include a receipt or bill that confirms what services were rendered on the date of service. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a stair glide.  You asked the Plan to pay for a stair glide. You say that you need this item. The Plan denied your request. The Plan says this is not a covered item.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue expander services provided on February 24, 2021.
You asked the Plan to pay for the services provided. You say that the tissue expander improves visualization.
The Plan denied your request. The Plan says the service is not separately reimbursable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 11960 is insertion of tissue expander(s) for other than
breast, including subsequent expansion. We find that CPT code 11960 was used to assist with the primary
procedure. It is inappropriate to separately report these services based on standard medical and surgical
principles. Based on this information, we decided that Medicare rules for coverage of the services provided
have not been met. Therefore, we decided that the Plan does not have to pay for the tissue expander services
provided on February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atorvastatin for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
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 Atorvastatin for the
enrollee.
Benefits for this drug 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve unlimited routine transportation trips.  You asked the Plan to pre-approve unlimited routine transportation. You say that you need additional transportation rides to dialysis treatment which you get three times a week. The Plan denied your request. The Plan says you receive unlimited number of rides to your PCP office and up to 48 one-way rides per year to other health care related locations. The Plan also says once those rides are exhausted, there are no additional rides available to non-PCP locations for the duration of the contract year.    Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers unlimited transportation rides to your primary care provider's (PCP) office. You are also covered for up to 48 one-way rides per year to other health care related locations, such as to the pharmacy or specialist appointments.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve unlimited routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99000) provided on July 6, 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 a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99000 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. 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 the services (99000) provided on July 6, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulatory surgical services received on
February 18, 2021.
You asked the Plan to waive the copayment for the services. You say that this should be waived. The Plan
denied your request. The Plan says the copayment is a contractual obligation.
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 $295
copayment for ambulatory surgery.
You have been asked to pay a $295 copayment for the services. The services fall within the ambulatory 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 ambulatory surgical services received on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the miscellaneous vision item/service (V2799) (custom lens option, blue-light lenses) provided on July 6, 2021.  You asked the Plan to pay for the custom lens option. You say that you do not understand what specific service this letter is referring to and you do not believe you owe this amount. The Plan denied your request. The Plan says the custom blue-light lens option is not listed as a covered service under your routine vision benefit. The Plan also says they contacted the provider and found that you paid for this service on the date of purchase, and you do not currently owe money for this service. You are not entitled to reimbursement for this lens option as it is not covered by your Plan, but you do not owe any additional payment.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover routine vision services or lens options that are not specifically listed as covered in the contract.  We looked at the file and the Plan's rules. While the Plan offers a vision benefit in excess of Medicare coverage, the requested lens option is not listed as covered under this benefit. Therefore, we decided that the Plan does not have to pay for the miscellaneous vision item/service (V2799) (custom lens option, blue-light lenses) provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for ultrasounds provided on August 4, 2021.  You asked the Plan to waive the deductible for the ultrasounds. You say that you should not be paying the full amount for these services The Plan denied your request. The Plan says the proper deductible was applied because the enrollee did not hit their deductible 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 $500 deductible before the Plan will pay their share for enrollees covered medical services and then you will pay your share of copayments or coinsurances amounts for the rest of the calendar year from an out-of-network provider. Prior to the date of service, the enrollee paid $0 in deductibles for the year. The total amount for the service was $397.92 which applied to the $500 deductible. Leaving the enrollee with only $102.08 ($500 starting deductible - $397.92 deductible for date of service) left to pay towards the deductible.  You have been asked to pay a $397.92 deductible for ultrasounds. The ultrasounds fall within the "what is your plan deductible" 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 deductible for ultrasounds provided on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76376) provided on August 23, 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 76376 is a column II code to column I code 78815. 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 (76376) provided on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health care.  You asked the Plan to pre-approve home health. You say that the enrollee needs continued home health monitoring of his condition and deteriorated cognitive state. The Plan denied your request. The Plan says the denial of authorization for additional home health visits is correct, because the enrollee does not meet coverage criteria.  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 home health. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found there is no documentation that additional skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition or to establish/perform a maintenance program. The records do not show any acute or unstable medical conditions or changes in medication which would necessitate further skilled nursing visits.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the removal of intact breast implants (19328).  You asked the Plan to pre-approve the removal of intact breast implants (19328). You say that you have severe neck and back pain due to the implants and need them removed. You say that this is not cosmetic it is due to continuous pain. The Plan denied your request. The Plan says this surgery is only supported in specific situations such as cancer, rupture or leaking of the implant, repeat infection from the implant, or scar tissue tightening around the implant. The Plan also says that the notes do not show these conditions apply and the surgery 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 the removal of intact breast implants (19328). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record does not indicate any failed attempt at conservative therapy, no contractures are present, and the implant is intact. Our reviewer says that the elements of the coverage criteria are not satisfied, and the requested service is not 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 the removal of intact breast implants (19328) have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of intact breast implants (19328).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on March 22, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service was rendered with no prior authorization.  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. Specifically, the case file does not include a claim or a provider remittance statement. There is no evidence of what was billed or how the denial has been substantiated. Therefore, we decided that the Plan has to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on March 22, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine provided on October 19, 2021.  You asked the Plan to pay for the services provided. You say that no one told you that you were going to be charged. The Plan denied your request. The Plan says the claim processed correctly.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules.   We looked at the file and the rules. The records do not show that you have been injured or directly exposed to any illness related to the services at issue. Based on this information, we decided that the Medicare rules for coverage have not been met.  Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on October 19, 2021.     Benefits for the services provided 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 11, 2021, to
June 5, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from May 11, 2021, to June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sedation services provided on July 20, 2021.  You asked the Plan to pay for the services provided. You say that the documentation supports the procedure was performed. The Plan denied your request. The Plan says the services were not billed as required by coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. We find that CPT code 99153 is a technical component only code. This service is not paid when billed by a physician in an outpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the sedation services provided on July 20, 2021.