Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree with the denial rational and ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says 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) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on April 8, 2021.

You asked the Plan to waive the copayment for outpatient hospital observation. You say that the enrollee should only owe an emergency room copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient hospital observation. 

The medical records show that the enrollee received outpatient hospital observation on April 8, 2021. Therefore, the enrollee is responsible to pay the $200 copayment. 

The enrollee has been asked to pay a $200 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation benefit category. 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 outpatient hospital observation provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for catheter supplies you received on May 19, 2021.
You asked the Plan to waive the cost sharing for the catheter supplies. You say that you believe the Plan's bills are confusing and you disagree with the amount you are being charged. The Plan denied your request. The Plan says you were charged this cost sharing 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 18% coinsurance for durable medical equipment and supplies. Records show that at the time you received these supplies, you still had $58.58 remaining on your deductible, so you were charged that amount. In addition, you have been asked to pay 18% coinsurance on the balance remaining after the deductible was satisfied for the catheter supplies.
The catheter supplies fall within the durable medical equipment and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for catheter supplies you received on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. You say that this is supported in the records. 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 thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary after the patient has had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). 

We looked at the file and Medicare rules. While the record shows that the enrollee has had two MBBs, the record shows that these MBBs were performed on different levels than the radiofrequency ablation at issue has been requested for. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional payment for the Davinci robotic surgical system (S2900).

You asked the Plan to pre-approve additional payment for the Davinci robotic surgical system. You say that you would like reconsideration because this surgical method has a high success rate and is all around the best option for the member. The Plan denied your request. The Plan says CPT code S9200 is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code S2900 is not supported. Specifically, per the Physician Fee Schedule, CPT code S9200 has a status indicator of I and is not valid for Medicare purposes. Please note, this review is solely in regard to whether additional payment may be made for CPT code S2900. Based on this information, we decided that Medicare rules for coverage of the Davinci robotic surgical system have not been met. Therefore, we decided that the Plan does not have to pre-approve additional payment for the Davinci robotic surgical system (S2900).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on October 6, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that this transport was needed as emergency behavioral health treatment. You say that there is no copayment for behavioral health care during 2020 due to the Coronavirus pandemic. 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 $270 copayment for ambulance services. 

You have been asked to pay a $270 copayment for the ambulance services. According to the Plan's website, your Plan only waived the following copayments in 2020 due to the Coronavirus pandemic: in-network primary care visits, outpatient behavioral health visits, and telehealth services. It does not include ambulance services, even if related to a behavioral health issue. 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 ambulance services you received on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure Injection services.

You asked the Plan to pre-approve the Repatha Sure Injection services. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit administered under this contract.

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 Repatha Sure Injection services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy procedure you had on April 30, 2021.

You asked the Plan to waive the copayment for the laryngoscopy procedure. You say that you did not know that this would be considered a surgery. 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 $100 copayment for outpatient surgery. 

You have been asked to pay a $100 copayment for the laryngoscopy procedure. The laryngoscopy procedure falls within the outpatient surgery 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 laryngoscopy procedure you had on April 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound of the heart provided on July 20, 2021.

You asked the Plan to waive the deductible for an ultrasound of the heart. You say that you disagree with the charges because you were pre-approved for the ultrasound. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $590 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 

The record shows that you received an ultrasound of the heart on July 20, 2021. The record shows that you had paid $0 toward the $590 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $304.08.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $590 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an ultrasound of the heart was received on July 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound of the heart provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for foot orthotics.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no reason to go out-of-network in this case.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral eustachian tube balloon dilation.

You asked the Plan to pre-approve bilateral eustachian tube balloon dilation. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.

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 bilateral eustachian tube balloon dilation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 77-year-old man who was evaluated on August 24, 2021, for ear fullness. Physical examination was notable for mild right tympanosclerosis. The left tympanic membrane was normal. There was no fluid in the middle ear bilaterally. The enrollee had a polyp of the nasal cavity. The enrollee's diagnoses include other chronic sinusitis, sensorineural healing loss, bilateral, Polyp of the nasal cavity, and other specified disorders of eustachian tube, bilateral. The documentation is insufficient to support that the enrollee has a medical condition for which bilateral eustachian tube balloon dilation would be 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 bilateral eustachian tube balloon dilation have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral eustachian tube balloon dilation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical nutrition therapy coded as 97802 and
97803.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you have other medical
conditions that your provider is now recommending medical nutritional therapy. The Plan denied your request.
The Plan says the enrollee does not meet the criteria as they do not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does
not have to pre-approve the medical nutrition therapy coded as 97802 and 97803.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).

You asked the Plan to pre-approve the mandibular partial denture. You say that you had cancer and are unable to chew because you have no bottom teeth. The Plan denied your request. The Plan says this service exceeds the benefit allowance.

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, complete and partial dentures are limited to once per arch per 60 months. The record shows that you received a mandibular partial denture (D5212) on February 21, 2020 and your mandibular denture benefit has been exhausted.

Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Anusol-Hc Sup 25mg.
You asked the Plan to pre-approve Anusol-Hc Sup 25mg. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says Anusol-Hc Sup 25mg is not covered under the
enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Anusol-Hc Sup 25mg.
Benefits for Anusol-Hc Sup 25mg 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the skilled nursing facility. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 skilled nursing facility. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Upon arrival to the SNF, the enrollee was ambulating more than 100 feet and tending to ADLs with minimal supervision. 

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 skilled nursing facility have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from June 16, 2021, to June 22, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had outpatient surgery services from June 10, 2021, to June 12, 2021. After your discharge from that surgery, you say that you developed pneumonia for which you had to be readmitted from June 16, 2021, to June 22, 2021. You said that you shouldn't have to pay the copayment for this admission because you developed pneumonia after surgery. 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 $360 copayment per day for days 1-5, and a $0 thereafter for inpatient hospital care.

You have been asked to pay a $360 copayment per day for days 1-5 for the inpatient hospital services. This copayment applies regardless of the reason for the admission. 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 you received from June 16, 2021, to June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diagnostic knee arthroscopy (29870).
You asked the Plan to pre-approve the diagnostic knee arthroscopy. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 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 the diagnostic knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for a knee scope not met. There is no documentation of adequate conservative measures to include physical therapy. 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 diagnostic knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve the diagnostic knee arthroscopy (29870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 18, 2021, to May 25, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 you must pay a $150 copayment for days 1-7 for inpatient hospital care. 

You had an inpatient hospital stay from May 18, 2021, to May 25, 2021. Therefore, you are responsible to pay a $150 copayment for days 1-7 (May 18, 2021, to May 24, 2021). The total amount you owe is: $150 (copayment) x 7 (inpatient days) = $1,050.

You have been asked to pay the total copayment amount of $1,050 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from May 18, 2021, to May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex device. You say that you hope for a favorable outcome to approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.