Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the continued skilled nursing facility (SNF) services provided from September 2, 2021, to September 8, 2021.  You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the care the enrollee required and received could have been rendered at lower level of care. The Plan also says that the enrollee did not receive services which Medicare would consider skilled.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a Notice of Medicare Non-Coverage (NOMNC) no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before September 1, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for the continued skilled nursing facility (SNF) services provided from September 2, 2021, to September 8, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says Trulicity is a once weekly non-insulin product.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intraoral periapical x-rays (D0220), D0230) for tooth #19.  You asked the Plan to pre-approve intraoral x-rays. You say that these services are necessary. The Plan denied your request. The Plan says you have already met your benefit limitation for periapical x-rays under your dental benefit. The Plan has covered six of these films within the last two years.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit coves one set of bitewing x-rays every two years or up to six periapical films every two years (not both).  Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan has already paid for six periapical films for you within the last two years. Therefore, we decided that the Plan does not have to pre-approve intraoral periapical x-rays (D0220), D0230) for tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the correction of trichiasis; epilation, by forceps only (67829) provided on September 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the removal of eyelashes using forceps. You say that your eye was irritated, and it didn't make sense to drive out to your doctor's office. The Plan denied your request. The Plan says care from out-of-network providers is not covered.  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 correction of trichiasis; epilation, by forceps only (67829) provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided on August 3, 2020, to August 10, 2020.  You asked the Plan to waive the copayment for the inpatient care. You say that you want to know which expenses were not covered by this claim and why they were not covered. You say you have a statement saying that the out-of-pocket maximum has been met. The Plan denied your request. The Plan says this inpatient stay was covered by the Plan. The claim was processed correctly, and the copayment was assessed in accordance with the enrollee's contract with the Plan. There is a $285 copayment required for each of the first six days of an inpatient hospital stay, with a $0 copayment for additional Medicare-covered days. ($285 x 6 = $1,710). The enrollee was admitted for a seven-day stay but was charged less than the full copayment amount because they met their out-of-pocket maximum at the time of service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $285 copayment for each of the first six days of an inpatient hospital stay. There is a $0 copayment for additional Medicare-covered days.  The enrollee has been asked to pay $1,673.41 for the seven-day inpatient stay. Documentation shows that at the time of these services, the enrollee met their out-of-pocket maximum for the year, and thus was not charged the full copayment amount. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided on August 3, 2020, to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left heart catheterization to be rendered by an 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.
You are 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 this service.
Therefore, we decided that the Plan does not have to pre-approve a left heart catheterization to be rendered by
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).  You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this because you are unable to lift filled tanks. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a portable oxygen system is covered if the beneficiary is mobile within the home and a qualifying blood gas study was performed while at rest (awake) or during exercise.  We looked at the file and Medicare rules. The medical records included in the file do not document that you have had a qualifying blood gas study that was performed while at rest (awake) or during exercise. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (01924) provided on July 30, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.  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 code 01924 is anesthesia for therapeutic interventional radiological procedures involving the arterial system; not otherwise specified.  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 anesthesia services. Our reviewer says that the documentation does not support the anesthesia services as billed. Our reviewer found that the anesthesia report documents procedures performed in which anesthesia was performed for are Ultrasound procedures Ultrasound-guided left femoral access with aortogram, right lower extremity runoff angiogram and tibial angiogram, right lower extremity via third-degree catheterization. Procedures documented in the anesthesia report does not support anesthesia for therapeutic interventional radiological procedures. A more appropriate anesthesia services to report for documented procedures would be for diagnostic procedures.  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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (01924) provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical implant placement (D6010), prefabricated abutment (D6056), and abutment supported crown (D6058) for tooth #19.  You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you feel they should be covered. The Plan denied your request. The Plan says these services are not covered by your dental 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 pre-approve a surgical implant placement (D6010), prefabricated abutment (D6056), and abutment supported crown (D6058) for tooth #19.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hand x-ray provided on October 15, 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 were rendered by an out-of-network 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 hand x-ray provided on October 15, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator (63650).  You asked the Plan to pre-approve the percutaneous implantation of neurostimulator (63650). You say that the patient has failed conservative treatment and is not getting long lasting relief with injections. You say that the treatment is a necessary option to provide long-term pain relief and the denial should be overturned. The Plan denied your request. The Plan says the member's coverage ended on December 31, 2021; therefore, the denial will be upheld.  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 percutaneous implantation of neurostimulator (63650). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the member does not have an evidence-based indication for a spinal cord stimulator trial.  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 percutaneous implantation of neurostimulator (63650) have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator (63650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration
because the requested procedure is medically necessary. The Plan denied your request. The Plan says the
requested procedure remains unproven and not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept Procedure is experimental and more research is needed to show its
safety and efficacy.
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 Intracept Procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept Procedure
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the leadless pacemaker insertion rendered on July 17, 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 services are not covered.  The Plan must follow Medicare rules. Medicare rules say that leadless pacemaker insertion is covered for FDA-approved studies.  We looked at the file and Medicare rules. The file shows that the services were not performed for an FDA-approved study. 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 leadless pacemaker insertion rendered on July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that based on the medical records provided, you believe the enrollee meets E0652 requirements for coverage. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on August 12, 2021, radiology services provided on August 17, 2021, and facility services provided from August 25, 2021, through August 26, 2021.  You asked the Plan to pay for the requested medical services. The Plan denied your request. The Plan says that without prior authorization services provided by out-of-network providers are not covered unless they are outside of the service area, emergency care or urgently needing services.  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 providers in this case are not network providers with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 12, 2021, radiology services provided on August 17, 2021, and facility services provided from August 25, 2021, through August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an opt-out provider on July 6, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering physician has opted-out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. This provider has opted out of Medicare until April 20, 22. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-out provider on July 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance and the deductible for a colonoscopy, flexible, with biopsy (45380) rendered on August 16, 2021.  You asked the Plan to waive the coinsurance and the deductible for a colonoscopy, flexible, with biopsy. You say that it is your understanding that if a polyp is found, it is removed and tested to prevent any further action, so a colonoscopy remains a preventative procedure unless it was ordered because of a prior existing symptom or symptoms. You also say that your colonoscopy was not. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that a screening colonoscopy can become a diagnostic colonoscopy during the procedure itself. If your physician orders a diagnostic colonoscopy then see "outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" for cost share. The Plan contract also says that enrollees must pay a 20% coinsurance for each Medicare-covered outpatient hospital facility visit, and the deductible does apply.   You have been asked to pay a $121 coinsurance, which is 20% of the allowed amount minus the deductible for a colonoscopy, flexible, with biopsy ($995.27 allowed amount - $390.28 deductible = $604.99), ($604.99 x 20% coinsurance = $121).   You have also been asked to pay $390.28 towards your deductible for a colonoscopy, flexible, with biopsy. A colonoscopy, flexible, with biopsy falls within the outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance and the deductible for a colonoscopy, flexible, with biopsy (45380) rendered on August 16, 2021.