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

We decided that the Plan does not have to pay fora Chest X-ray (71045) provided November 16, 2019. You asked the Plan to pay forthechest x-ray. You say that the x-ray was medically necessary.The Plan denied your request. The Plan says routine pre-operative chest x-rays are not medically necessary.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 chest x-ray. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee apparently underwent a chest x-ray as part of a pre-operative evaluation for non-thoracic surgery. There is no indication that the enrollee had respiratory signs, symptoms or known disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora Chest X-ray (71045) provided November 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean esophagogastroduodenoscopy  (43235).You asked the Plan to pre-approvean esophagogastroduodenoscopy. You say that this is necessary because you also have sleep apnea.The Plan denied your request. The Plan says the record does not show you have had a colonoscopy that fails to show the source of blood loss.The Plan must follow Medicare rules. Medicare rules say that esophagogastroduodenoscopies are covered for presence of gastrointestinal bleeding for presumed chronic blood loss and for iron deficiency anemia when a colonoscopy is negative.We looked at the file and Medicare rules. The record shows that this service was ordered due to iron deficiency. However, the record does not show that you have had a negative colonoscopy. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met.Therefore, we decided that the Plan does not have to pre-approvean esophagogastroduodenoscopy  (43235).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional dental extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210).You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says your request exceeds the allowable benefit as approval was issued previously for two dental extractions.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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Specifically, your request exceeds the allowable benefit per calendar year as the Plan previously issued authorization for two dental extractions. Therefore, we decided that the Plan does not have to pre-approve five additional dental extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided on December 3, 2019 to December 17, 2019 by a Licensed Marriage & Family Therapist.
You asked the Plan to pay for the mental health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a Licensed Marriage & Family Therapist is ineligible to enroll in Medicare.
The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. The services you received in this case were provided by a Licensed Marriage & Family Therapist (LMFT). This provider type is not eligible to enroll in Medicare. No provider shall receive payment for services furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the mental health services provided on December 3, 2019 to December 17, 2019 by a Licensed Marriage & Family Therapist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2018.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, wedecided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for after cataract laser surgery provided on December 4, 2019.You asked the Plan to waive the copayment for after cataract laser surgery. You say that without this procedure your vision would continue to deteriorate. You say that the procedure should be paid for.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 $400 copayment for surgery services at an in-network outpatient hospital.You have been asked to pay a $400 copayment for after cataract laser surgery. After cataract laser surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 after cataract laser surgery provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a prothrombin time test provided on January 10, 2019.
You asked the Plan to pay for the prothrombin time test. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a prothrombin time test provided on January 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
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 preapprove a pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox for the enrollee.You asked the Plan to pre-approveBotox. The Plan denied your request. The Plan says a retail pharmacy will be used for the purchase of Botox.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveBotox for the enrollee. Benefits for Botoxmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment providedon January 7, 2020.You asked the Plan to pay for the chiropractic treatment. You say that your wife's friend recommended this chiropractor. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our Plan, you must use network providersto get your medical care and services.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 Plandid not pre-approve the chiropractic treatment. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for chiropractic treatment provided on January 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2018 to March 22, 2018.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were received by a provider who is not participating with Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.
The requested provider in this case is not a network provider with the Plan, and was not eligible to provide service under Original Medicare. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 11, 2018 to March 22, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Nitro DLX Euro Style Rollator.You asked thePlan to pre-approvea Nitro DLX Euro Style Rollator. You say that the enrollee has fallen while using a standard walker.The Plan denied your request. The Plan says the enrollee was authorized for a standard walker.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. We looked at this the file and Medicare rules.Medicare covers a standard rollator.Based on this information, we decided that Medicare rules for coverage of a Nitro DLX Euro Style Rollator have not been met.Therefore, we decided that the Plan does nothave to pre-approvea Nitro DLX Euro Style Rollator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 1, 2019 through October 4, 2019 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were taken to a non-participating facility and had no control over where you were taken. The Plan denied your request. The Plan says even though you were taken to an out-of-network provider the Plan processed the claim with your in-network benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted to an out-of-network provider on October 1, 2019 and discharged on October 4, 2019. You were asked to pay a $295 copayment per day from October 1, 2019 through October 3, 2019, days 1-3 of your inpatient hospital care. You were discharged on October 4, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-5. Therefore, the claim processed with your in-network benefits. 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 care from October 1, 2019 through October 4, 2019 provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan services provided on
December 9, 2019.
You asked the Plan to waive the copayment for the CT scan services. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received CT scan services on the date of service at issue in this appeal. The
Plan states the correct copayment has applied per your contract with the Plan.
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 $225
copayment for CT scan services performed by a provider other than your primary care physician.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received CT scan services
provided by a provider other than your primary care physician on December 9, 2019. You have been asked to
pay a $225 copayment for the CT scan services. The CT scan services fall 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 CT scan services provided on
December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe diagnostic vascular services provided on November 8, 2019.You asked the Plan to waive the copayments forthe diagnostic vascular services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plansays you received physician services on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $20 copayment for Physician/Practitioner services. We looked at the file, the Plan contract and Medicare rules. The fileshows that you received diagnostic vascular services on November 6, 2019 and November 8, 2019. You have been asked to pay a $20 copayment for each of the diagnostic vascular services. The diagnostic vascular services fall within the Physician/Practitionerservices 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 copayments forthe diagnostic vascular services provided on November 8, 2019.Your complaint about your provider ordering a test in error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that you want the continued services covered for the member. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found the health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941, 97014) provided on October 21, 2019 to October 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON chiropractic services. You say that you believed you were in-network.The Plan denied your request. The Plan says these services were not authorized.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 has network providers available who can provide 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 chiropractic services (98941, 97014) provided on October 21, 2019 to October 22, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 9, 2019 through December 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 9, 2019 through December 20, 2019.
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.