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

We decided that the Plan does not have to pre-approve anesthesia for approved diagnostic or therapeutic nerve blocks and injections.
You asked the Plan to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections (01992). You say that you seize and stop breathing when under stress or pain. The Plan denied your request. The Plan says your doctor did not document any unstable medical condition that would necessitate monitored anesthesia care.
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 anesthesia for diagnostic or therapeutic nerve blocks and injections (01992). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found general anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on re-determination for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. There is no specific indication for general anesthesia, conscious sedation or Monitored Anesthesia Care (MAC) for intra-articular facet joint injections or medical branch blocks. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for approved diagnostic or therapeutic nerve blocks and injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee continues to have complex
needs. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
The enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nitroglycerin, Losartan, Aspirin, Atenolol, and Amlodipine provided on April 30, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you were not given any medication. The Plan denied your request. The Plan says self-administered drugs are not Part B covered.

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 Nitroglycerin, Losartan, Aspirin, Atenolol, and Amlodipine provided on April 30, 2021.

Benefits for the self-administered drugs 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 pay for the ambulance response and treatment with no transport (A0998) provided on February 23, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell, and your neighbor called the ambulance despite your opposition. You also say that when the ambulance arrived you told them you were a retired physician and did not want help. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 
The ambulance company did not provide transport services on February 23, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 6, 2021.
You asked the Plan to pay for the surgical extraction. You say that this was a surgical procedure which your dentist diagnosed as necessary to prevent infections. The Plan denied your request. The Plan says this service is not covered by 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. The only type of extractions that are covered under your plan are non-surgical extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the arm joint.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a recent six-week trial of doctor-prescribed treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the records document general shoulder pain, with mild degenerative changes seen on plain radiographic imaging. The records do not document any failure of six weeks of provided-directed conservative treatment. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the arm joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lasik eye surgery.
You asked the Plan to pre-approve Lasik eye surgery. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Lasik eye surgery is not covered by Medicare or the Plan's
supplemental vision benefit.
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.
We looked at the file and the Plan's rules. Though the Plan offers a supplemental vision benefit for additional
coverage, Lasik eye surgery is not covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve Lasik eye surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve InterGro DMB Allograft procedure (20930, 20931).
You asked the Plan to pre-approve InterGro DMB Allograft procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the use of this product during spinal surgery is better than standard allograft products.
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 InterGro DMB Allograft procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intergrow DBM allograft is experimental. More research is needed to show safety and efficacy of this device before coverage will be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of InterGro DMB Allograft procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve InterGro DMB Allograft procedure (20930, 20931).
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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 70-year-old female with schizophrenia, hypertension, chronic obstructive pulmonary disease, atrial fibrillation and sacral fracture. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
January 11, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had to use to
ambulance to go to rehabilitation from the hospital. You say the Plan should pay more than $6.93. 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 $250
copayment for each one-way Medicare-covered ground trip. For this date of service, you have been asked to
pay the allowed amount of the claim because this amount is less than the standard $250 copayment for the
ambulance transport.
You have been asked to pay a $239.58 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance 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 waive the copayment for
the ambulance transport provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle/foot orthotic (AFO).

You asked the Plan to pre-approve an AFO. You say that the item is medically necessary. The Plan denied your request. The Plan says you already have this item and duplicates are not covered.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has an anfle/foot orthotic (AFO) and the requested item serves the same purpose as an AFO. Therefore, we decided that the Plan does not have to pre-approve an ankle/foot orthotic (AFO).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-approve a 
colonoscopy to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on April 22, 2021.
You asked the Plan to pay for a panoramic radiographic image. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare of the Plan.
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. 
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. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the thoracic MRI.
You asked the Plan to pre-approve thoracic magnetic resonance imaging (72157). You say that you need the MRIs because you have a lot of lower back pain. The Plan denied your request. The Plan says you do not meet criteria for a chest MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 thoracic magnetic resonance imaging (72157). Our reviewer says that the service is not medically reasonable or necessary. Our physician reviewer found there is no specific clinical rationale for the requested MRI of the chest. The requested MRI of the chest is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thoracic magnetic resonance imaging (72157) have not been met. Therefore, we decided that the Plan does not have to pre-approve the thoracic MRI.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the measurement of bladder capacity provided on April 27, 2021.
You asked the Plan to waive the copayment for the measurement of bladder capacity. You say that the procedure should be included in your specialist copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $35 copayment for specialist services, including surgery services. You received the measurement of bladder capacity on April 27, 2021. The measurement of bladder capacity is considered an outpatient surgical procedure. The record shows that you already paid a $35 specialist copayment. Therefore, the measurement of bladder capacity should be included in the specialist copayment and the Plan must waive the additional $10 copayment. The Plan says you must pay a $10 copayment for the measurement of bladder capacity. Based on the Plan contract, however, you cannot be asked to pay more than a $35 copayment for specialist services, which include the measurement of bladder capacity. Therefore, we decided that the Plan has to waive the copayment for the measurement of bladder capacity provided on April 27, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of an upper extremity joint (73221) provided on April 7, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you have a limited income and you did not know that this diagnostic service would cost this much when you had it done at the hospital. The Plan denied your request. The Plan says this 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 $275 copayment for advanced imaging services provided in an outpatient hospital setting.

You have been asked to pay a $245.31 copayment for the MRI. The MRI falls within the advanced imaging services benefit category, and in this case, it was performed in an outpatient hospital setting. 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 magnetic resonance imaging (MRI) of an upper extremity joint (73221) provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the medical records are not clear when describing the member's relief to previously tried interventions.
The Plan must follow Medicare rules. Medicare rules say that facet joint injections are covered if the LCD 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 requested services are not considered medically reasonable and necessary in this
case. It is unclear exactly how much relief was gained from previous ablations and injections. The pain scale
used is not consistent throughout each encounter and makes it difficult to evaluate pain relief. Also, to be noted,
your arthritis may play a part in her pain and lack of pain relief based on previous flare-ups. Our physician
reviewer found that your condition does not meet Medicare criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections (64493, 64494).