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

We decided that the Plan does not have to pre-approve Dexamethasone 0.5/5ml elx for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage ls limited only to those drugs covered under the medical benefit.
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 Dexamethasone 0.5/5ml elx for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility services provided from 05/06/2021 to 05/16/2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the services should be covered as you cannot afford to pay 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 $178 copayment per day after day 20 of Skilled nursing facility (SNF) care.
You have been asked to pay a $178 copayment for ten days of SNF care (05/06/21 - 05/16/21) 10 x $178 =
$1,780. The record indicates that these services were provided in network and that you were discharged on
05/16/21, the plan does not charge a copayment for this date. 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 skilled nursing facility services provided from 05/06/2021 to 05/16/2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable, and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parenteral medication, complex wound care, or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near the baseline. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery provided on June 8, 2021.
You asked the Plan to waive the copayment for the cataract surgery. You say that you were dissatisfied with the services provided and feel you should not be responsible for this cost. The Plan denied your request. The Plan says they are addressing your concerns in a separate grievance, but the copayment for this claim was applied in accordance with your contract.
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 $30 copayment for services with a specialist. You have been asked to pay a $30 copayment for cataract surgery. The cataract surgery falls within the specialist 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 cataract surgery provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Sudomotor function testing (95923) provided July 7, 2021.
You asked the Plan to pay for Sudomotor function testing. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the testing performed does not meet the requirements needed to support autonomic nervous system function testing.
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 has not provided any information that substantiates their reason to deny. There is no information showing that the claim was coded incorrectly or that the service is not covered. Therefore, we decided that the Plan has to pay for Sudomotor function testing (95923) provided July 7, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services (11643) provided on June 16, 2021.
You asked the Plan to pay for code 11643. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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, we have confirmed that code 11643 is a column II code to column I code 17313. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the excision services (11643) provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services received while in Mexico from March 18, 2021 to April 15, 2021.
You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received were not medically necessary.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 medical services. Our reviewer says that the documentation does not support that the services received were medically reasonable or necessary. Our physician reviewer found the documentation shows that you could have foreseen requiring the services prior to leaving your service area. The records indicate that the care provided or requested was not medically necessary.
It would have been medically reasonable to delay the services until you returned to the service area (or disenrolled from the plan or up to 6 months if date unknown - whichever is earliest). The review indicates that the surgery was not emergent, and you chose to continue care out of plan and returned to Mexico for surgery. It appears you were traveling back and forth from Mexico to Los Angeles and could have been cared for in Plan. Therefore, the services received were 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services received while in Mexico from March 18, 2021 to April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on July 28, 2021.
You asked the Plan to pay for the dental service. You say that you cannot afford this bill. The Plan denied your
request. The Plan says comprehensive periodontal evaluation is not listed as a covered service.
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 comprehensive periodontal
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the comprehensive periodontal evaluation (D0180) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee treats his diabetes with Metformin, Ozempic, and an injection of Toujeo 100 units once daily.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle
Libre for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (blood work/blood count) provided to the enrollee on October 9, 2020.
You asked the Plan to pay for the services. You say that this should be covered as a wellness preventive at 100%. The Plan denied your request. The Plan says this was done for screening purposes.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available guidelines do not supported a repeated prostate specific antigen (PSA) test past age 85, nor is there record of recent change in cholesterol-lowering therapy to justify repeat lipids or comprehensive metabolic panel (CMP). As the enrollee had prior history of hyperlipidemia, and no recent signs of hypothyroid, the thyroid stimulating hormone (TSH) test was not justified. Complete blood count (CBC) was also not justified as there were no indications for such in the note. Therefore, without sufficient support made for these tests, they will be considered not medically necessary 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (blood work/blood count) provided to the enrollee on October 9, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the vestibuloplasty (40845) services provided on April 27, 2021.
You asked the Plan to pay for code 40845. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as 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 has not provided any documentation showing that codes 40845 and 20969 cannot be submitted and paid together on the same claim. Therefore, we decided that the Plan has to pay for the vestibuloplasty (40845) services provided on April 27, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea.
You asked the Plan to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 insertion or replacement of a neurostimulator system for treatment of central sleep apnea. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare will not provide coverage of transvenous phrenic nerve stimulation for central sleep apnea as a review of published literature does not support the medical necessity for this service at this time. Under Medicare, the request is not medically necessary. The review has determined that the items/services at issue in this case are not medically reasonable or 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 insertion or replacement of a neurostimulator system for treatment of central sleep apnea have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of a neurostimulator system for treatment of central sleep apnea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that per the guidelines, these injections should give relief for three months.
The Plan must follow Medicare rules. Medicare rules say that for epidural injections to be repeated, there must be 50% pain relief for at least three months. The file shows that this will be third injection at the same level in a span of three months. The initial injection should have given pain relief for three months. It is too soon to attempt a fourth injection at the same anatomic site. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care can be received in another setting.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the X-Spine Axle interspinous fusion system.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the X-Spine Axle Interspinous Fusion System has not been demonstrated in the peer-reviewed literature.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this system is experimental for use in spinal surgery. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the X-Spine Axle interspinous fusion system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) provided on tooth #'s 22, 23, 24, 25, 26,
and 27 on August 11, 2021.
You asked the Plan to pay for the crowns. You say that this should be covered. The Plan denied your request.
The Plan says crowns are not covered for wear due to abrasion. As such, this was denied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns
when the services are medically necessary and reasonable.
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 crowns. Our reviewer says that the
coverage criteria for the provided crowns have not been met. Our physician reviewer found in this instance the
records clearly indicate the major reason for restoration with crowns was the heavy wear across the lower anterior teeth, though there were some slight carious lesions around the necks for some of the teeth. It was not indicated that the teeth involved (not specified) would not be able to be restored with conventional restorative materials. The provided x-rays do no show significant caries at the cervical region such that crowns would be required to restore the teeth. The primary rationale for restoration with crowns was due to the previous heavy wear patterns across the incical edges, a noted exception under the Plan rules. Given the provided records, the requested treatment would not meet the Plan's criteria for fixed prosthodontics. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pay for the crowns (D2740) provided on tooth #'s 22, 23, 24, 25, 26, and 27 on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer/Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer/Vertiflex device.