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

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this request is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve a therapeutic continuous glucose monitor
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on January 29, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that you would like the insurance to cover this test since it was ordered immediately by your operating doctor. 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 Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay a $100 copayment for the duplex scan. The duplex scan 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 the duplex scan provided on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, abdomen (74150) computed
tomography, pelvis (72192) computed tomography, abdomen and pelvis (74176)

You asked the Plan to pre-approve the diagnostic service. You say that you requested CPT code 74177 to be
covered. It was denied and you are asking this to be approved. The enrollee is having on going diarrhea and
cramping. The enrollee also has a history of diverticulitis. The Plan denied your request. The Plan says the
records do not support the Medicare criteria and is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the diagnostic service. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's complaints predate her 6/2021 colonoscopy, the results of which proved
reassuring. However, standard of care evaluation of chronic diarrhea warrants as medically necessary and
appropriate the following studies which were not provided in enrollee's case: basic lab work including routine
CBC and chemistry screen, stool tests to exclude pathogens, Giardia, testing for celiac disease, testing for
inflammatory markers, including fecal calprotectin, testing for fecal occult blood. Without the above initial
studies and assessment of Xifaxan response, CT imaging of the abdomen and/or pelvis is premature, and
therefore not medically reasonable and necessary at this juncture in enrollee's care of chronic diarrhea.

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 diagnostic service have not been met. Therefore, we decided that the Plan
does not have to pre-approve computed tomography, abdomen (74150) computed tomography, pelvis (72192)
computed tomography, abdomen and pelvis (74176)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office consultation (99244) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office consultation. You say that this care is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide for the enrollee's medical needs.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office consultation (99244) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Computed Tomography (CT) scan (70450) provided April 27, 2021.

You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is not separately payable.

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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a Computed Tomography (CT) scan (70450) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 29,
2021.
You asked the Plan to pay for the periodontal maintenance. You say that the last time this procedure was
performed was on November 5, 2020, which is more than 6 months ago. The Plan denied your request. The
Plan says you have reached your benefit maximum amount 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal cleanings are limited to 1
every 6 months. The record shows that you received a periodontal maintenance (D4910) on November 5, 2020,
and your periodontal cleanings benefit had been exhausted. Therefore, we decided that the Plan does not have
to pay for the periodontal maintenance (D4910) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 the office visit provided on November 12, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021 by an outof-
network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The 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 the laboratory
services provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 24, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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 the drug testing provided on February 24, 2021 by a non-participating provider.
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 an IRF is the appropriate level of care for this enrollee and a denial will have a detrimental effect on their recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee is likely unable to tolerate 3 hours of intensive therapy at least 5 days per week. The necessary care can be provided in an alternate setting.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is 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 a 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 requested procedure is still considered experimental/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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided December 10, 2020.

You asked the Plan to pay for the lab 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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.

We looked at the file and Medicare rules. The record does not show an order from the treating physician for this service. 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 lab services (81479) provided December 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on February 22, 2021
by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

Medicare rules say that plans can require enrollees to obtain prior authorization for certain services.

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 psychotherapy
services provided on February 22, 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 the maxillary partial denture (D5213) and replacement of broken teeth (D5640) provided on April 26, 2021.
You asked the Plan to pay for the maxillary partial denture and replacement of broken teeth. You say that you were not provided with the paperwork of all your coverage from the Plan. You also say that you believe part of these services should be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 maxillary partial denture (D5213) and replacement of broken teeth (D5640) provided on April 26, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve hysterectomy and cystoscopy services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that there is no documentation that a full workup has been performed.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee presented with abnormal uterine and vaginal bleeding, unspecified. The enrollee has a stable submucosal fibroid. It is documented that you had very heavy bleeding and pelvic pain during her last few periods. She did then have some breakthrough bleeding, and a lot of fatigue. The enrollee tried Lysteda again, which did decrease the total amount of bleeding. The enrollee declined hormonal options. The requested services are indicated for the enrollee's condition. Abnormal uterine bleeding is an accepted indication for the management of abnormal uterine bleeding. The documentation supports that the requested hysterectomy and cystoscopy are medically reasonable and necessary for the enrollee in this case.

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 requested services have been met. Therefore, we decided that the Plan has to pre-approve hysterectomy and cystoscopy services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this equipment is medically necessary for your
condition. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for radiation therapy provided from May 17, 2021, to June 3, 2021.
You asked the Plan to reduce the copayments for radiation therapy. You say that you would appreciate it if the copayment was lowered because you are undergoing treatment for breast cancer and the cost is adding up. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for radiation therapy visits. You received radiation therapy from May 17, 2021, to June 3, 2021, for a total of 10 visits. Therefore, you are responsible to pay a $60 copayment per each visit. The total amount you owe is: $60 (copayment) x 10 (radiation therapy visits) = $600. You have been asked to pay the total copayment amount of $600 for radiation therapy.
Radiation therapy 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 reduce the copayments for radiation therapy provided from May 17,
2021, to June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the back procedure (Intracept Intraosseous Nerve
Ablation System) (C9752).

You asked the Plan to pre-approve the back procedure. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is experimental.

The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices 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 back procedure. Our reviewer says
that the requested service is not considered medically reasonable and necessary in this case. Our physician
reviewer found this is an experimental procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the back procedure have not been met. Specifically, the requested procedure is
experimental. Therefore, we decided that the Plan does not have to pre-approve the back procedure (Intracept
Intraosseous Nerve Ablation System) (C9752).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the CLIA certification level is not met.

The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs
. 
We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 pay for the laboratory services rendered on May 4, 2021.