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

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the
lumbar spine provided on April 14, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you had the procedure done at a
different location. The Plan denied your request. The Plan says you have been charged 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 $150
copayment for advanced imaging services provided in an outpatient hospital facility, including MRI's.
You have been asked to pay $110, which is less than the $150 copayment for the MRI. The MRI falls within
the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for magnetic resonance imaging (MRI) of the lumbar spine provided on
April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a targeted genomic sequence panel.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when
specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you have metastatic prostate cancer that
has spread to the bone. The documentation does not show that you have decided to seek further cancer
treatment, such as therapeutic chemotherapy. The records do not support that the requested testing is reasonable
and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a targeted genomic sequence panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided July 22, 2021.
You asked the Plan to pay for the full mouth debridement. You say that you would like this 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided July 22, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of current implant and placement of LinQ
implant.
You asked the Plan to pre-approve the removal of current implant and placement of LinQ implant. You say that
the requested removal of current implant and placement of LinQ implant is medically necessary. The Plan
denied your request. The Plan says the requested removal of current implant and placement of LinQ implant 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 current implant and
placement of LinQ implant. Our reviewer says that the requested removal of current implant and placement of
LinQ implant is not medically necessary. Our physician reviewer found while the enrollee has a history of
atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic
stroke, or any other apparent indication for an implantable loop recorder (ILR). In summary, there is
insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's clinical
management.
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 current implant and placement of LinQ implant have not been
met. Therefore, we decided that the Plan does not have to pre-approve the removal of current implant and
placement of LinQ implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 21, 2021.  You asked the Plan to pay for the problem focused oral exam. You say that you have only had 2 oral exams. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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 covers the problem focused oral exam once every 12 months.  We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on August 26, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided May 10, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided from May 26, 2021, to May 28, 2021.
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the cost share prior was lower. The Plan denied your request. The Plan says the proper coinsurance was applied.
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 In-Network surgery performed at an Outpatient Hospital Facility. The first total amount allowed was $12351.73 and the coinsurance amount was $2470.35 ($12351.73 x 20% coinsurance). The second amount allowed was $108.60 and the coinsurance amount was $21.72 ($108.60 x 20% coinsurance). The total amount of coinsurance allowed during the date(s) of service was $2492.07 ($2470.35 + $21.72).
You have been asked to pay a 20% coinsurance for In-Network Outpatient surgery. The outpatient surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the outpatient surgery provided from May 26, 2021, to May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal puncture (62328) provided on August 26, 2021.
You asked the Plan to pay for the spinal puncture (62328). You say that the procedure was rendered in an appropriate place of service and the claim should be reconsidered for payment. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service 22 (outpatient) when the member was an inpatient.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule, the Place of service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. In this case, the CPT Code Manual definition of code 62328 is spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance. We find that CPT code 62328 is not supported in the medical record. Specifically, the member was an inpatient at the time the service was received. The claim was billed with POS 22 (outpatient) and should have been billed with POS 21 (inpatient). Based on this information, we decided that Medicare rules for coverage of the spinal puncture (62328) have not been met. Therefore, we decided that the Plan does not have to pay for the spinal puncture (62328) provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the replacement/revision of InterStim device.  You asked the Plan to pre-approve the replacement/revision of InterStim device. You say that the requested replacement/revision of InterStim device is medically necessary. The Plan denied your request. The Plan says the requested replacement/revision of InterStim device is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the replacement/revision of InterStim device. Our reviewer says that the requested replacement/revision of InterStim device is not medically necessary. Our physician reviewer found although Interstim impedance check indicates the presence of several impedances, the medical records clearly state that her urge incontinence is reasonably well controlled. As such, revision 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 replacement/revision of InterStim device have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement/revision of InterStim device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 6, 2021, by an OON
provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to
verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your
request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on April 6, 2021, by
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Respimat (J3535).
You asked the Plan to pre-approve the Spiriva Respimat. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 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 Spiriva Respimat (J3535).
Benefits for the Spiriva Respimat 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve renal ultrasound and related services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no recent documentation detailing the current clinical condition and necessity of the requested services.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have had a diagnosis of asymptomatic bilateral renal cysts since 2012. The computed tomography (CT) scans performed in 2012, 2016 and 2020 showed that the cysts were unchanged. The renal ultrasounds performed in 2013, 2016, and 2019 showed that the cysts were unchanged. The medical records dated 3/1/21 showed that the cysts were unchanged and had no symptoms. 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 pre-approve renal ultrasound and related services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda) and bevacizumab (Avastin).
You asked the Plan to pre-approve pembrolizumab (Keytruda) and bevacizumab (Avastin). You say that the
requested pembrolizumab (Keytruda) and bevacizumab (Avastin) are medically necessary. The Plan denied
your request. The Plan says the requested pembrolizumab (Keytruda) and bevacizumab (Avastin) are not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 pembrolizumab (Keytruda) and
bevacizumab (Avastin). Our reviewer says that the requested pembrolizumab (Keytruda) and bevacizumab
(Avastin) are not medically necessary. Our physician reviewer found the requested use of Keytruda and
Avastin are not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug
compendia or by clinical research that appears in a CMS-approved medical journal.
Trial is phase II and other treatments are available such as single agent bevacizumab, gemcitabine and others.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pembrolizumab (Keytruda) and bevacizumab (Avastin) have not been met.
Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda) and bevacizumab
(Avastin).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) outpatient office visit and x-rays provided July 12, 2021 to July 14, 2021.
You asked the Plan to pay for the chiropractic services. You say that you are requesting reimbursement for the chiropractic services provided. The Plan denied your request. The Plan says these claims were processed with the correct copayments applied. The Plan covers only manual manipulation of the spine to correct subluxation.
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 $15 for
each Medicare covered visit for Chiropractic services.
You have been asked to pay $172 ($15 + $15 + $142) for the chiropractic services. Chiropractic services are
not eligible for reimbursement under the Wellness Allowance. The x-rays and office visit are not covered under
the Plan benefits when rendered by a chiropractor. The chiropractic services fall within the Chiropractic
services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98941)
outpatient office visit and x-rays provided July 12, 2021 to July 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Arformoterol Tartrate.  You asked the Plan to pre-approve Arformoterol Tartrate. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Arformoterol Tartrate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation in the case file does not support that Perforomist (formoterol) would likely be less effective, and/or would likely have adverse effects for you.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arformoterol Tartrate have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol Tartrate.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary, as help is still needed for daily activities. The Plan denied your request. The Plan says all of the needed services are offered at the inpatient rehabilitation facility (IRF).
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 the admission. Our reviewer says that
the requested admission is not medically or necessary. Our physician reviewer found you have stabilized
medically, and have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF).
You have tolerated inpatient rehabilitation services, and continue to improve with daily skilled nursing and/or
skilled therapy services. You would continue to benefit from services at the current level of care. You have
made slow progress with therapy, and there is no indication that a transfer to a skilled nursing facility would be
required. You can continue to receive care at the same level or be stepped down ot a lower level of care when
appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission
to a SNF for inpatient skilled rehab services 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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).