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

We decided that the Plan does not have to pre-approve FDG PET.
You asked the Plan to pre-approve FDG PET. You say that you would like reconsideration because the PET is medically necessary and urgent. The Plan denied your request. The Plan says the records do not support that the member meets diagnostic criteria for both Alzheimer's disease and Frontotemporal Dementia.
The Plan follows Medicare rules. Medicare rules say that FDG PET scan is considered reasonable and necessary in patients who meet diagnostic criteria for both Alzheimer's disease and Frontotemporal Dementia. 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 FDG PET. Our reviewer says that Medicare coverage criteria for the requested service have not been met. Our physician reviewer found the medical records did not readily support that the member is suspected of having either Alzheimer's disease or Frontotemporal Dementia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FDG PET have not been met. Therefore, we decided that the Plan does not have to pre-approve FDG PET.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging provided
on August 26, 2020.
You asked the Plan to waive the copayment for the magnetic resonance imaging, spinal canal and contents
(72146). You say that you were told the Plan waived all charges because of COVID-19. 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 Diagnostic Tests.
You have been asked to pay a $100 copayment for the magnetic resonance imaging, spinal canal and contents
(72146). The magnetic resonance imaging, spinal canal and contents (72146) falls within the Outpatient
Diagnostic Tests 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 magnetic
resonance imaging provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory virus screening (87631) provided on November 13, 2020.
You asked the Plan to pay for a respiratory virus screening. You say that this should be covered. The Plan denied your request. The Plan says this was a screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a respiratory virus screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a respiratory virus screening (87631) provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the nutrition therapy services provided to you on November 18, 2020.
You asked the Plan to pay for the nutrition therapy services. You say that your EOC doesn't give limits for this service. The Plan denied your request. The Plan says that the benefit has been exhausted.
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 documentation submitted by the Plan does not contain records showing that previous medical nutrition therapy services were processed and paid by the Plan. The Plan does not indicate how and when the limit was reached for this benefit. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the nutrition therapy services provided to you on November 18, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy, flexible, proximal to splenic flexure
(45380) provided on June 2, 2020, by an OON provider.
You asked the Plan to pay for the colonoscopy. You say that you respectfully request reconsideration of
payment as services were provided in good faith and were deemed medically necessary. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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 colonoscopy, flexible, proximal to splenic
flexure (45380) provided on June 2, 2020, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose blood test, cardiopulmonary resuscitation, insertion of non-tunneled centrally inserted central venous catheter, ED visit, and Adrenalin epinephrine injection provided on February 16, 2020.
You asked the Plan to pay for the glucose blood test, cardiopulmonary resuscitation, insertion of catheter, ED visit, and Adrenalin epinephrine injection. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the glucose blood test, cardiopulmonary resuscitation, insertion of non-tunneled centrally inserted central venous catheter, ED visit, and Adrenalin epinephrine injection provided on February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that this device was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says items that are used for a preventative service or function are excluded from coverage.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12 and 14 and core buildups, including any pins when required (D2950) for tooth #'s 12 and 14.

You asked the Plan to pre-approve the crowns and core buildups. You say that the crown work you previously received was done incorrectly. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.

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, crown (D2740) and core buildup, including any pins when required (D2950) are each limited to one procedure per tooth every five plan years. The record shows that you received a crown (D2740) and core buildup (D2950) on tooth #12 and a crown (D2740) and core buildup (D2950) on tooth #14 and your crown (D2740) and core buildup (D2950) benefits for tooth #'s 12 and 14 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 12 and 14 and core buildups, including any pins when required (D2950) for tooth #'s 12 and 14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.

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. Medicare rules say that a sleep study is covered when specific criteria are met.

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 morbid obesity, diabetes with complications, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and congestive heart failure. The medical history documentation does not include a detailed sleep history or assessment of excessive daytime sleepiness. A review of systems obtained during a telehealth visit indicates the patient "denies sleep disturbance." There is no mention of snoring, observed apneas, or daytime sleepiness. Thus there is no documented clinical basis for the diagnosis of suspected sleep apnea, and the sleep study is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on August 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
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 skilled nursing services provided on August 28, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance provided by an out-of-network provider.

You asked the Plan to pay for the lower extremity MRI (73718). You say that you did not know the procedure
was not authorized. The Plan denied your request. The Plan says you did not request 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 service at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that
the Plan does not have to pay for the magnetic resonance provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81286, 81404, 81407,
81408, 81479) provided on September 9, 2020.
You asked the Plan to pay for cardiomyopathy risk factor screening. You say that this was medically necessary.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients
with suspected or documented CV disease because panel testing is not specific to a given patient's lipid
abnormality or disease.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of cardiomyopathy risk factor
screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy risk
factor screening (81286, 81404, 81407, 81408, 81479) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that you went to the office for MOHS surgery but were advised they did not do that surgery. The Plan denied your request. The Plan says the copayment 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 $30 copayment for each specialist visit for Medicare-covered benefits (Including Telehealth services).

You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, including Doctor's Office Visits" benefit category. The records show that you were examined, received skin education and referred for surgery. 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 office visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.

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. The ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided 
that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 14, 2019, and March 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on March 14, 2019, and March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care provided on January 9, 2020 and January 16, 2020.
You asked the Plan to waive the copayment for the hospital outpatient clinic visits. You say that you did not know you would have a copayment for the wound care. The Plan denied your request. The Plan says you were charged less than your copayment because the allowed amount was less.
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 $225 copayment for Outpatient Hospital Services. You have been asked to pay $235.48 copayment for the hospital outpatient clinic visits. The hospital outpatient clinic visits fall within the Outpatient Hospital Services benefit category. The allowable amount for the services was less than your copayment. 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 wound care provided on January 9, 2020 and January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239).

You asked the Plan to pay for the hospital discharge day management. You say that the services were medically necessary. The Plan denied your request. The Plan says this service can only be paid once per hospital stay.

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 99239 is not supported in the medical record. Specifically, only one hospital discharge day management service is payable per patient, per hospital stay. The service was already paid once for this stay. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2020 by an out of network (OON) provider.
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 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 referring provider 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 laboratory services provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) mechanical traction (97012) manual electrical stimulation (97032) application of a modality to 1 or more areas; whirlpool (97022) outpatient office visit (99213) provided August 12, 2020 to October 21, 2020.
You asked the Plan to pay for the chiropractic services. You say that the enrollee was seen as a new patient on 08/12/2020 for pain that has been bothering her since 08/08/2020. The enrollee was recommended by the doctor to start the VAX D therapy. The Plan denied your request. The Plan says the services are not covered when rendered by a chiropractor.
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. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) mechanical traction (97012) manual electrical stimulation (97032) application of a modality to 1 or more areas; whirlpool (97022) outpatient office visit (99213) provided August 12, 2020 to October 21, 2020.