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

We decided that the Plan does not have to pre-approve excision of excess skin.

You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says cosmetic surgery or expenses incurred in connection with such surgery is not covered.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

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 procedures. Our reviewer says that the requested procedures are not medically reasonable or necessary. Our reviewer found he record indicates that the enrollee had previously had panniculectomy and abdominoplasty. The records provided do not indicate recent injury. The record does not indicate that function would be improved by the requested procedure. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.

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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve excision of excess skin.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extracranial arteries (93880) provided on March 15, 2021.
You asked the Plan to pay for a duplex scan of extracranial arteries. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a diagnosis that supported medical necessity.
The Plan must follow Medicare rules. Medicare rules say that Medicare established coverage for code 93880 limited to specific diagnosis codes. Diagnosis codes I10, E78.00, and Z87.891 are not listed as covered. We looked at the file and Medicare rules. The service at issue was billed with diagnosis codes I10, E78.00, and Z87.891, which are not listed as supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of a duplex scan of extracranial arteries have not been met.
Therefore, we decided that the Plan does not have to pay for a duplex scan of extracranial arteries (93880) provided on March 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services you received on May 11, 2021.

You asked the Plan to waive the deductible for the podiatry services. You say that you thought you would only have a $35 copayment for these services. The Plan denied your request. The Plan says you had not yet satisfied your deductible at the time you received these services. That is why you were charged the full allowed amount. Once you meet your deductible then the $35 copayment for podiatry services will apply.

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 a $750 deductible which applies to podiatry services. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to podiatry services. This cost sharing is a contractual obligation that had not been met at the time the podiatry services were received on May 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services you received on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept provided on March 12, 2021.
You asked the Plan to pay for paramedic intercept. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that paramedic provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic intercept provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625).
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that this is necessary to avoid surgery. The Plan denied your request. The Plan says this has not been shown to be more beneficial than standard treatments.
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 sacroiliac joint radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found adiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker with seat attachment.
You asked the Plan to pre-approve a walker with seat attachment. You say that you are unable to stand upright and walk for more than a minute at a time. The Plan denied your request. The Plan says that you have a walker you were given in 2019.
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 you have a standard walker. a standard walker serves the same purpose as a walker with seat attachment. Therefore, we decided that the Plan does not have to pre-approve a walker with seat attachment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided on June 24, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the provider told you that you were due for a 
mammogram. 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 mammogram provided on June 24, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nerve block procedure (64454) provided May 12, 2021.
You asked the Plan to pay for the nerve block procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says this procedure was experimental and non-covered.
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 pay for the nerve block procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. 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 nerve block procedure have not been met. Therefore, we decided that the Plan does not have to pay for a nerve block procedure (64454) provided May 12, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam.
You asked the Plan to pre-approve Lorazepam. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 pre-approve Lorazepam.
Benefits for Lorazepam 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for an osteogenesis stimulator (E0748) provided on November 3, 2020.
You asked the Plan to pay for an osteogenesis stimulator. You say that you have submitted the requested documentation multiple times. The Plan denied your request. The Plan says that the records do not support the item billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's original denial states that the records do not support the service billed, but the Plan has not provided information about what documentation was needed and not present. The documents submitted include an order, proof of delivery, and medical records. The documents also indicate that the Plan issued prior authorization for this item. Therefore, we decided that the Plan has to pay for an osteogenesis stimulator (E0748) provided on November 3, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF services provided from
February 26, 2021, through April 17, 2021.
You asked the Plan to waive the copayment for SNF services. You say that the bill is too much for you to pay. The Plan denied your request. The Plan says SNF services were rendered from February 26, 2021, through March 13, 2021, March 25, 2021, through March 31, 2021, and April 1, 2021, through April 17, 2021. This totals 38 days of skilled nursing services during the benefit period. Per your Evidence of Coverage, for each admission you pay $20 per day for days 1-20 of a benefit period, and $60 per day for days 21-44 of a benefit period.
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 for each admission you pay $20 per day for days 1-20 of a benefit period, and $60 per day for days 21-44 of a benefit period, and $0 per day for days 45-100 of a benefit period for Skilled nursing facility (SNF) care.
You have been asked to pay $20 per day for days 1-20 of a benefit period, and $60 per day for days 21-44 of a benefit period, and $0 per day for days 45-100 of a benefit period for SNF services. SNF services falls within the skilled nursing facility (SNF) care 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 SNF services provided from February 26, 2021, through April 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services provided on April 28, 2021.
You asked the Plan to waive the deductible for lab services. You say that the deductible does not apply to lab services. The Plan denied your request. The Plan says the deductible applied was correct.
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 a $500 deductible which applies to Medicare-covered lab services. The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to Medicare-covered lab services. This cost sharing is a contractual obligation that had not been met at the time lab services were received on April 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services provided on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided July 6, 2020.

You asked the Plan to pay for the ambulance response. You say that it was safer for you to be treated in your
home than be transported and the services should be covered. The Plan denied your request. The Plan says the
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

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 July 6, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment,
no transport (A0998) provided July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous positive airway pressure (CPAP) backup 
battery. 
 
You asked the Plan to pre-approve a CPAP backup battery. You say that you need this to be able to sleep. The 
Plan denied your request. The Plan says that alternative power sources are not considered by Medicare as 
durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Continuous positive airway pressure (CPAP) backup 
battery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and electrical stimulation rendered on June 
14, 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. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor submitted claims for procedure codes 99203 (office visit) and G0283 (electrical stimulation). 
Therefore, we decided that the Plan does not have to pay for the office visit and electrical stimulation rendered 
on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic visit (99214) to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve the office visit. You say that the services are 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
orthopedic visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on 
May 24, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you don't think there should be an extra 
charge for an ECG done at the doctor's office. You said that you already paid the copayment for the office visit. 
The Plan denied your request. The Plan says you were charged this copayment 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 $10 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $10 copayment for the ECG. The ECG falls within the diagnostic procedures and 
tests benefit category. Your contract states that if you receive additional services during an office visit, 
additional cost sharing will apply for those services. 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 electrocardiogram (ECG) you had on May 
24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953 x 3), non-intravenous conscious sedation (D9248), alveoloplasty not in conjunction with extractions, 1 to 3 teeth per quadrant (D7321), alveoloplasty not in conjunction with extractions, 4 or more teeth per quadrant (D7320), implants (D6010 x 4), and a semi-precision attachment abutment (D6052).

You asked the Plan to pre-approve the dental services. You say that your dentist feels that you need these services due to other medical conditions that are causing the dental issues. The Plan denied your request. The Plan says the requested services are not listed as covered dental 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, the requested bone replacement grafts, conscious sedation, alveoloplasties, implants, and abutments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953 x 3), non-intravenous conscious sedation (D9248), alveoloplasty not in conjunction with extractions, 1 to 3 teeth per quadrant (D7321), alveoloplasty not in conjunction with extractions, 4 or more teeth per quadrant (D7320), implants (D6010 x 4), and a semi-precision attachment abutment (D6052).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.
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 an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that records document that the enrollee is independent with dressing, grooming, and eating, thus indicating that the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.