Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), prophylaxis (D1110), and resin-based composite (D2392) provided on July 26, 2021, and August 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the periodic oral evaluation, intraoral periapical x-rays, prophylaxis, and resin-based composite. You say that you were not aware that this treating provider was not in-network, or that you had to use an in-network provider. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the total amount of $276 applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for the difference between the billed amount and allowed amount for these services because they were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), prophylaxis (D1110), and resin-based composite (D2392) provided on July 26, 2021, and August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
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 Botox is covered for specific indications only. 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 the enrollee has sciatica and piriformis syndrome. These are not listed as covered indications for Botox in the Medicare rules. The services are therefore not reasonable or 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 Botox.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services and electrocardiogram interpretation provided on June 16, 2021, billed with primary diagnosis code T40.2X5A.
You asked the Plan to pay for the medical services as billed. You say that this was coded correctly and should be paid. The Plan denied your request. The Plan says this was coded with a manifestation code as the primary diagnosis. This is not allowed per ICD-10 guidelines.
The Plan must follow Medicare rules. Medicare rules say that some codes have Code First notes which require that an etiology code be reported prior to the manifestation code. In this case, diagnosis codes within the T36-T40 range have a Code First note stating that if the code is for an adverse effect of a substance, the adverse effect must be coded first. In this case, T40.2X5A is defined as Adverse effect of other opioids, initial encounter. As such, the adverse effect should be coded as primary. Therefore, we decided that the Plan does not have to pay for the emergency room services and electrocardiogram interpretation provided on June 16, 2021, billed with primary diagnosis code T40.2X5A.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0429 and A0425), provided on August 27, 2021.

You asked the Plan to waive the copayment for the ambulance service. You say that you should not be responsible for the copay. The Plan denied your request. The Plan says the cost share 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 $240 copayment for ambulance services. 

You have been asked to pay a $240 copayment for the ambulance service. This 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 (A0429 and A0425), provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair for the enrollee.
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary. The Plan denied your request. The Plan says because the enrollee is able to the control power tilt with its own switch, there is no need to control the power option through the joystick.
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 electronic connection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the electrical connection (E2311) is not medically necessary, as the enrollee's upper extremity strength and function support that the enrollee can control any power options through 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 the electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).

You asked the Plan to pre-approve Synvisc. You say that you believe the enrollee would significantly benefit from Synvisc. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.

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 Synvisc. Our reviewer says that Synvisc (J7325) is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, Orthovisc and Monovisc. Our reviewer also found that the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be improving and should only require short-term additional acute care services that can be safely received at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the contrast exam rendered on February 10, 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 procedure code 75625 is not supported.  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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation.  We find that CPT code 75625 is not supported in the medical record. Specifically, there is no documentation of radiological supervision and interpretation of an abdominal aortography by serialography. 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 contrast exam rendered on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
August 16, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the benefit of a $250 allowance was applied to the purchase leaving you with a responsibility of $544, which was paid at the time of purchase.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan applied the $250 allowance to the purchase of your eyeglasses, and you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for A-C IOLs provided on June 23 to July 20, 2020.

You asked the Plan to pay for A-C IOLs. You say that the items at issue were a medical necessity for you. The Plan denied your request. The Plan says the items at issue are not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. 

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for A-C IOLs provided on June 23 to July 20, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the observation discharge day management services rendered on July 13, 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 that the services were not billed correctly.

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 states that billed procedure code 99217 (observation discharge, day management) was not correct for the date of service billed; however, the Plan has not provided any documentation to support that the claim is not paid as billed. Therefore, we decided that the Plan has to pay for the observation discharge day management services rendered on July 13, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on August 16, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service, advanced life support, emergency transport, level 1. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee was transported via ambulance from the nursing facility to the hospital with reported abnormal labs (Hgb 6.3) after recent hip replacement surgery and possibly
needing transfusion. The enrollee's vitals were stable. She was able to ambulate to the cot with a walker. No
treatment was received during transport. The enrollee's presenting symptoms did not meet prudent layperson
criteria for emergency care. The documentation does not support that other means of transport, such as
stretcher van, were contraindicated for this enrollee. The documentation does not support that the enrollee
needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped
ambulance can provide for safe transport. The documentation does not support that the ambulance transport on
August 16, 2021 was medically reasonable and necessary for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1 have not
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life
support, emergency transport, level 1 (A0427, A0425) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on August 11, 2021, through September 24, 2021.

You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because you were told additional visits would be covered. The Plan denied your request. The Plan says you are covered for acupuncture services for a total of 25 per year.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.

As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record indicates that you have exhausted this benefit as you have already received 25 acupuncture sessions. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on August 11, 2021, through September 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits.  You asked the Plan to pre-approve the additional PT visits. You say that you have Sciatica in your back. You also say that you cannot get around well due to the pain, and your doctor feels that therapy might help you. The Plan denied your request. The Plan says there has been minimal improvement in your leg strength, and the range of motion in your back has decreased. The Plan also says that the four approved PT visits followed by a home exercise program should meet your therapy needs.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have previously been treated with outpatient therapies and should be independent with a home exercise program. Our reviewer found that there is no documentation of a recent injury or decline in function. Our physician reviewer also found that the additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore 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 the additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 29, 2020.
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 procedure code 99204 is not supported.
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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components. We find that CPT code 99204 is not supported in the medical record. Specifically, the file shows that the enrollee was previously seen by this provider on August 20, 2020; August 22, 2020; August 25, 2020; and August 26, 2020; therefore, a new patient office visit does not apply. 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 office visit rendered on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (CPT code 77049), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the screening breast MRI is medically necessary. The Plan denied your request. The Plan says the service is not necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found the enrollee has a family history of breast cancer but no personal history of breast cancer. Most recent digital mammography from 2021 showed no evidence of malignancy. MRI from 2020 showed a moderate diffusely increased bilateral background enhancement but no mass seen. Repeat screening breast MRI was requested. The provided records did not show that that prior imaging or recent examination, signs or symptoms warranted repeat MRI at this time. Therefore, the enrollee does not meet criteria for this request for MRI. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (CPT code 77049), for the enrollee.