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

 We decided that the Plan does not have to pay for the Tempus Gene Panel provided on April 14, 2021.  You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this testing was not billed correctly.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the Tempus Gene Panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any clinical information. Without this information we are unable to determine why this testing was ordered, how it will affect the member's treatment or if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on October 21, 2021.  You asked the Plan to waive the copayment for a comprehensive eye examination. You say that under your policy it says you do not have a copay for eye exams because you are a diabetic. The Plan denied your request. The Plan says that according to the medical records, a medical eye exam was performed on this date of service. The provider documented a diagnosis of cataracts in both eyes, drusen (yellow deposits under the retina), in both eyes and other disorders of the optic nerve in both eyes. You were found to not have diabetic retinopathy, but the other conditions were also addressed on this date of service. This cost sharing is a contractual obligation you agreed to when you enrolled with the Plan. Therefore, you will remain liable for the $20 copayment that applied for the medical eye exam.  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 copayment for Vision Care, Medical Eye Exam.   You have been asked to pay a $20 copayment for a comprehensive eye examination. The comprehensive eye examination falls within the Vision Care, Medical Eye Exam benefit category. This means that you been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart without contrast material with quantitative evaluation of coronary calcium.  You asked the Plan to pre-approve a (CT) of the heart. 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 follows Medicare rules. Medicare rules say that coronary artery calcium (CAC) scoring using ultrafast cardiac CT is only covered for certain indications.  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(CT) of the heart. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is asymptomatic from a cardiovascular standpoint and has no other cardiac risk factors according to her physician. Numerous studies have demonstrated that coronary artery calcium (CAC) scoring using ultrafast cardiac CT adds predictive value in assessing risk of coronary heart disease (CHD). In one study a score of zero was associated with a CHD risk of 1-6%, while a CAC score over 300 was associated with a risk of 13-26%. Clinical studies have not, however, shown that CAC scoring adds value in clinical management of asymptomatic patients in whom risk factors are targeted. Mamadu in 2014 examined whether CAC scoring in asymptomatic adults might have an effect on behavior modification, risk perception, and medication adherence. While CAC screening improved medication adherence, the impact of CAC scoring on behavioral and lifestyle factors, perception of CHD risk, and psychosocial effects was not statistically significant compared with baseline. In summary, current evidence showing that the use of CAC scores in clinical management of asymptomatic individuals leads to changes in patient management or in individual risk behaviors that improve cardiac outputs outcomes is limited and inconclusive.  Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal management of this patient. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation and management of this enrollee's medical condition.  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 (CT) of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart without contrast material with quantitative evaluation of coronary calcium.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray provided on October 28, 2021.  You asked the Plan to waive the copayment for an x-ray. You say that the x-ray was done in a stand-alone facility which provides radiology services and is not a clinic nor a hospital. The Plan denied your request. The Plan says the x-ray was provided by a contracted facility and the proper copayment 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 $90 copayment for each covered X-ray in the outpatient department of a network hospital or facility.     You have been asked to pay a $90 copayment for an x-ray. An x-ray falls within the Outpatient diagnostic test 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 an x-ray provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve caudal epidural steroid injections (ESI).  

You asked the Plan to pre-approve caudal epidural steroid injections (ESI). 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 follows Medicare rules. Medicare rules say that caudal epidural steroid injections (ESI) are only covered for certain indications.  

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 caudal epidural steroid injections (ESI). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of chronic low back pain secondary to lumbar spinal stenosis, spondylosis with lumbar radicular pain, and sacroiliac arthritis, left hip. The enrollee has been treated with medical therapy. The enrollee had a caudal epidural steroid injection (ESI) on November 17, 2021, which provided 60-85% pain relief. A repeat ESI is done when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the same scale for at least three months. In this case, it has not been quite three months since the last injection. Therefore, the enrollee does not meet criteria for the requested 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 caudal epidural steroid injections (ESI) have not been met. Therefore, we decided that the Plan does not have to pre-approve caudal epidural steroid injections (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), first intraoral periapical x-ray (D0220), and crown (D2740), or pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0272), panoramic x-ray (D0330), and prophylaxis (D1110) provided on August 30, 2021, and September 7, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the core buildup, first intraoral periapical x-ray, and crown, and to pay more for the periodic oral evaluation, bitewing x-rays, panoramic x-ray, and prophylaxis. You say that the fax sent by the Plan to the provider shows a $0 deductible, an annual maximum of $2,000.00, and 100% coverage for the services you received. The Plan denied your request. The Plan says core buildup is not a covered expense under your dental plan.  The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.  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, core buildup, including any pins when required (D2950) is not among those covered under this benefit. You are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), first intraoral periapical x-ray (D0220), and crown (D2740), or pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0272), panoramic x-ray (D0330), and prophylaxis (D1110) provided on August 30, 2021, and September 7, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opdivo (J9299) in combination with Yervoy (J9228).  You asked the Plan to pre-approve Opdivo and Yervoy. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of the requested drugs have not been demonstrated.  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 Opdivo and Yervoy. Our reviewer says that the requested drug combination is not medically necessary. Our physician reviewer found the enrollee is a 79-year-old male with a diagnosis of stage IV non-small cell lung cancer poorly differentiated cutaneous squamous cell carcinoma. In this case, the use of Opdivo and Yervoy is not FDA-approved for the enrollee's medical condition because it is indicated as first line therapy and this enrollee has had prior line of therapy. Furthermore, the use of the requested drugs is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299) in combination with Yervoy (J9228).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on July 2, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided May 21, 2021.  

You asked the Plan to waive the copayment for the emergency ambulance service. You say that you were told it was not your fault you required an ambulance transport back to the hospital so you don't feel you should be responsible for the copayment. 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 each way Medicare-covered ground trip.  

You have been asked to pay a $250 copayment for the emergency ambulance service.  

The emergency ambulance service 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 service, basic life support, emergency transport (A0429) provided May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on May 9, 2021.  You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says criteria have not been met.    The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on May 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repair services for a backup power wheelchair.  You asked the Plan to pre-approve repair services. You say that this is medically necessary in case the enrollee's primary power wheelchair fails. The Plan denied your request. The Plan says coverage is not provided for maintenance services for a backup device.  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 a primary power wheelchair that they use. This power wheelchair serves the same purpose as the backup wheelchair that needs repairs. Therefore, we decided that the Plan does not have to pre-approve repair services for a backup power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral hygiene instruction (D1330) and adjunctive pre-diagnostic test (D0431) provided on August 17, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that these services would not be covered. You say that the dental office advised you should come in anyways. You say that you were advised services that were not covered would not be done. You also say that no one gave you any instruction on care. The Plan denied your request. The Plan says oral hygiene instruction is not listed as a covered service. The Plan says that adjunctive pre-diagnostic testing is not listed as a covered service either.  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 oral hygiene instructions and adjunctive pre-diagnostic testing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene instruction (D1330) and adjunctive pre-diagnostic test (D0431) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four removals of residual tooth roots (D7250 x4) and problem focused limited oral evaluation (D0140) provided on May 24, 2021, and September 17, 2021.  You asked the Plan to pay for the removals of residual tooth roots and problem focused limited oral evaluation. You say that these were emergency extractions with infections in the gum, and you believe they should be covered. The Plan denied your request. The Plan says the removals of residual tooth roots are not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds 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, removal of residual tooth roots (D7250) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 30, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four removals of residual tooth roots (D7250 x4) and problem focused limited oral evaluation (D0140) provided on May 24, 2021, and September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for podiatry services provided on July 26, 2021.  You asked the Plan to waive the deductible for the podiatry services. You say that you would not have gone to this provided if you knew they were out of network. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 there is $1500 out-of-network (OON) deductible which applies to certain items and services.   The item or service you asked the Plan to waive the deductible for falls within the Podiatry Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1500 out-of-network (OON) deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the podiatry services were received on July 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services provided on July 26, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography angiography (CTA) of the abdominal aorta.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that services that are not medically necessary are not covered by the plan.  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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found you have bilateral lower extremity claudication, and ulceration of the right great toe. Arterial ultrasound has revealed elevated peak systolic velocity of the left Common femoral artery at 226cm/sec raising the possibility of focal stenosis. X-rays of the right foot showed extensive small vessel arterial calcifications indicative of advanced atherosclerosis. CTA has been requested to include lower extremity runoff as a potential pre op screening tool for vascular repair. This request is very reasonable and should be approved especially given the abnormal arterial ultrasound.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography angiography (CTA) of the abdominal aorta.   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.