Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for a pulmonary function test provided on June 18, 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 the copayment applied correctly based on the services provided.
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 failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for a pulmonary function test provided on June 18, 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 pay for lens enhancements of anti-reflective coating, UV lens, polycarbonate lens and progressive lens provided on September 9, 2021.

You asked the Plan to pay for lens enhancements. The Plan denied your request. The Plan says lens enhancements are not a covered benefit.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan's vision care benefit does not provide coverage for lens enhancements. Therefore, we decided that the Plan does not have to pay for lens enhancements of anti-reflective coating, UV lens, polycarbonate lens and progressive lens provided by on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (15271) provided March 15, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 15271 is not supported in the medical record. Specifically, the operative report does not document the use of a skin substitute that requires fixation. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met.

Therefore, we decided that the Plan does not have to pay for surgical services (15271) provided March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reduction.
You asked the Plan to pre-approve breast reduction. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 breast reduction. Our reviewer says that the documentation does not support that the requested breast reduction is medically reasonable or necessary. Our reviewer found the enrollee has an elevated lifetime risk of breast cancer with PALB2 and CHEK2 mutations.
The records do not support that the breast reduction improves function or repairs injury. The records provided do not indicate that the enrollee has had an injury or has a malformed body member that requires improved functioning. Therefore, the enrollee does not meet criteria for the requested services. Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38914 to support their denial. However, LCD L38914 is not valid for the enrollee's home state of Rhode Island. Therefore, we are unable to use LCD L38914 to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reduction have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reduction
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lumbar-sacral orthosis provided on July 27, 2021.

You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that the brace was uncomfortable so you purchased a different one. The Plan denied your request. The Plan says the correct 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 a 20% coinsurance for each durable medical equipment (DME) item. 

You have been asked to pay a $151.18, which is 20% of the allowed amount for the lumbar-sacral orthosis ($755.90 allowed amount x 20% coinsurance = $151.18). The lumbar-sacral orthosis falls within the Durable Medical Equipment (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 lumbar-sacral orthosis provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that you cannot push a larger oxygen tank around the home or even outside the home. The Plan denied your request. The Plan says you have not been fully tested for oxygen treatment, including for a portable concentrator.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. It appears that the plan requested medical records multiple times without success. Without the medical records, the requested services cannot be verified. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin provided on July 19, 2021.
You asked the Plan to pay for the insulin. You say that you told the nurse you did not want the insulin because they advised you had to take it, it was expensive, and you would have to pay for it. The Plan denied your request. The Plan says insulin is a self-administered drug and is not covered. The Plan also says that insulin is a Part D medication.
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 pay for the insulin provided on July 19, 2021.
Benefits for the insulin 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: Favorable

We decided that the Plan has to pay for portable radiology services (R0075) provided to the enrollee on July 14, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the provider reported transportation of portable radiology equipment, but did not report setup codes, which does not follow industry standard coding rules.
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, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code R0075 is "Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen." We asked our coder 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 services at issue in this case were supported by the medical records. Our reviewer found the HCPCS coding system follows Centers for Medicare and Medicaid Services (CMS) guidelines. Per CMS guidelines, transportation of x-ray equipment is only billable when the equipment is transported from outside of the facility where services are being performed. In this case R0070 and R0075 would be reported with the appropriate revenue code. When the x-ray equipment is stored in the facility were the services are being performed, then a set up only code would be reported - Q0092. No clear documentation was found to support billing of HCPCS codes R0070 or R0075 with Q0092. We looked at this coder'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 pay for portable radiology services (R0075) provided to the enrollee on July 14, 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 pre-approve a bilateral three level therapeutic cervical facet injection 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 there have not been two previous diagnostic injections at the proposed therapeutic site, and there is no rationale for why the enrollee needs three injections bilaterally.
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 the review has determined that there is no evidence of any unique clinical circumstance that would require a three-level procedure. The enrollee has not received the proper relief from diagnostic injections to indicate a therapeutic injection. There is no documentation of why the enrollee would not be a candidate for radiofrequency ablation. 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 a bilateral three level therapeutic cervical facet injection for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 Vertiflex procedure. 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 indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has multi-level degenerative disease in the lumbar region and has undergone Vertiflex placement at L4-L5. The Vertiflex device may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and Drug Administration states that the requested procedure is contraindicated if a decompression procedure at the index level has been performed.
The record provided does not state that the enrollee is not indicated for operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the denosumab injection provided on May 18, 2021.

You asked the Plan to pay for the denosumab injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not a covered benefit.

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. Review of the file shows that only three pages were submitted to Maximus for this case file. The three pages submitted included the case file submission form only. Maximus requested the rest of the case file (Initial authorization request, Plan's initial denial, reconsideration request, Plan's reconsideration determination, and any medical records used in making your decision) without response from the Plan. This means the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the denosumab injection provided on May 18, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on July 16, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you want the Plan to pay an additional amount. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery in an ambulatory surgical center. You have been asked to pay a $195 copayment for a diagnostic colonoscopy. The records show that the Plan had advised you that your cost would be $195 instead of $250.
The service at issue falls within the outpatient surgery in an ambulatory surgical center 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 a diagnostic colonoscopy provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on June 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for anesthesia services. You say that the facility and/or surgeon are in-network with the Plan and therefore, the claim should be processed at the in-network benefit level. The Plan denied your request. The Plan says the anesthesia services at issue were provided by an out-of-network provider and the enrollee was also referred by an out-of-network provider. Furthermore, the Plan says the services were neither urgent nor emergent and were not subject to pre-approval.

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 anesthesia services provided on June 29, 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 contact lenses provided on July 6, 2021.
You asked the Plan to pay for contact lenses. You say that the contact lenses are medically necessary. The Plan
denied your request. The Plan says your policy only covers contact lenses after cataract surgery.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, the Medicare rules and the Plan's rules. The services you asked the Plan to pay for are considered routine eyewear for contact lenses. The file shows that the Plan and Medicare do not cover contact lenses. Therefore, we decided that the Plan does not have to pay for contact lenses provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 5, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you were not aware that you had to wait three years to get another set of x-rays. You also say that these services were necessary because your gums were in bad shape. The Plan denied your request. The Plan says these services exceed the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on March 26, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthotic device
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this device is considered investigational due to the lack of clinical evidence demonstrating an impact on improved 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed.
The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 the MyoPro orthotic device