Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection with arthrography for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that although the injections are being allowed, the arthrography is not considered to be medically necessary, as it is investigational.

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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the plan is allowing the injection but not the arthrography. The injection of contrast insures that the injectate is within the joint, and demonstrates the spread of the local anesthetic and steroid mixture. It is a standard of care, and is medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve a sacroiliac joint injection with arthrography for the enrollee.

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 pre-approve an inpatient admission for a video
electroencephalogram (95719) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the inpatient procedure. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says there are network providers available.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an
inpatient admission for a video electroencephalogram (95719) to be provided by an out-of-network (OON)
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional rides to get to and from your dialysis appointments. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 24 one-way trips to Plan approved locations every year.
We looked at your request, the records in the case file, and the rules. The records show that you have used twenty-two (22) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 24 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on June 22, 2021.

You asked the Plan to reimburse you for hearing aids. You say that these are the third pair of hearing aids that you have went through trying to find the best ones and these are the least expensive of the three. The Plan denied your request. The Plan says you must see the Plan's hearing aid provider to receive the benefit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a brolucizumab-dbll injection (J0179) and vision care office visit (99214) provided on March 8, 2021.
You asked the Plan to waive the copayment for the brolucizumab-dbll injection and vision care office visit. You say that the services should be covered, and you do not feel like you should have to pay for them. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $25 copayment for Vision care.
You have been asked to pay a 20% coinsurance a brolucizumab-dbll injection (allowed is $1,889.7 x 20% = $377.94) and a $25 copayment for a vision care office visit. Brolucizumab-dbll injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a brolucizumab-dbll injection (J0179) and vision care office visit (99214) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on March 2, 2021.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0480) provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 1, 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 testing is not covered.
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, a hereditary cardiac risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the patient would greatly benefit from Prolia. The Plan
denied your request. The Plan says this request does not meet the Plan's Part B coverage criteria for Prolia.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
elements of the coverage criteria are not satisfied. Our physician reviewer found the provided records do not
indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Zoledronic Acid. Our
reviewer also found that the record does not indicate that the enrollee has a contraindication to, or would have
an adverse effect from the Plan's preferred step one alternative.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 10, 2020, to May 15, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services
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 $360 copayment per day for days 1-5 of Inpatient hospital care.
You have been asked to pay a $720 copayment for five days of inpatient hospital services, which is less than the $360 per day for days 1-5 stated in the Plans contract. 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 inpatient hospital services provided from May 10, 2020, to May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist new patient office visit and a follow up visit
(99215, 99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist new patient office visit and a follow up visit. You say that the
provider the Plan is redirecting you to does not know how to treat your issues. The Plan denied your request.
The Plan says that this provider is not a network provider and that the medical care you require can be provided
by a network provider.
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 provider at issue in this case is not a network provider with the Plan. 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 specialist new patient office visit and a follow up visit. Our reviewer says
that this does not meet criteria. Our physician reviewer found the record provided does not establish the
medical necessity and reasonableness, as defined by Medicare rules, of the requested service.
The Plan has network providers that can provide the necessary care at this time. Our doctor also found that the elements of the coverage criteria are not satisfied, and the requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a specialist new patient office visit and a follow up visit have not been met. 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 a specialist new patient office visit and a follow up visit. Therefore, we decided that the Plan does not have to pre-approve a specialist new patient office visit and a follow up visit (99215, 99205) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the referral is not medically necessary.
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network referral is not medically necessary. Our physician reviewer found the submitted records do not show that you require a referral to the requested provider for active treatment and continued care. The Plan has network providers that are able to provide the same level of care as the requested provider. Your care can be transitioned to an in-network provider at this time. 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. 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 services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose device.

You asked the Plan to pre-approve the requested services. You say that you need this therapy for quality of life. The Plan denied your request. The Plan says coverage criteria 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 does not indicate that you have diabetes mellitus, 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
resin-based composite (D2392) provided on October 4, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and resin-based composite. You say
that you feel that the re-filling should be covered or the payment to the original provider should be rescinded
and credited to you or your account so you can pay this treating provider. The Plan denied your request. The
Plan says the problem focused limited oral evaluation is not a covered expense under your dental Plan. The
Plan says that your benefits for the resin-based composite have been satisfied and the frequency limitation has
been exceeded. The Plan also says that you contacted the Plan on August 17, 2021, were educated on your
benefits for fillings, and were also mailed your code specific benefits which lists the frequency limitations for
fillings.
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, problem focused limited oral
evaluation (D0140) is not among those covered under this benefit. The contract says that restorations (fillings)
are limited to two procedure codes per calendar year. Therefore, we decided that the Plan does not have to pay
for the problem focused limited oral evaluation (D0140) and resin-based composite (D2392) provided on
October 4, 2021.
Your complaint about the disappointing experience you had with the original provider is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on
March 5, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the
member was transferred from the hospital after hitting her head. The Plan denied your request. The Plan says
this claim has not been billed correctly by the provider.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules. The rules also say that for ambulance services, a secondary diagnosis must be reported.
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 ambulance services have not been met. Specifically, the documentation
submitted does not include any clinical information to verify if Medicare criteria for coverage have been met.
Additionally, this claim was not billed with the required secondary diagnosis code. Therefore, we decided that
the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient surgery services provided on December 29, 2020, and March 30, 2021.

You asked the Plan to waive the copayments for the surgery services. You say that you were wrongfully charged, the coding was wrong on the bills, and you never had surgery only the 2 injections. The Plan denied your request. The Plan says the provider billed properly for these services and the proper copayments were 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 $250 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $500 copayment for the surgery services. The surgery services 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 copayments for outpatient surgery services provided on December 29, 2020, and March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from February
7, 2022 onward.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 services are not medically necessary. Our physician reviewer found you were admitted to the hospital
January 4, 2022 with major neurocognitive disorder with behavioral disturbance. You were compliant with
treatment and and do not have suicidal or homicidal ideation. You deny auditory and visual hallucinations. It is
not medically necessary to to have psychiatric care provided at the inpatient level of care, as you are not
showing dangerousness to self or others. It does not appear that the services are reasonably expected to
improve your condition or for the purpose of diagnosis. It does not appear that active treatment is taking place.
Continued inpatient services are not medically necessary.
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 continued inpatient psychiatric services from February 7, 2022 onward.