Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forcrisis intervention (H2001) provided on February 10, 2019.You asked the Plan to pay forthe crisis intervention. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this is not a Medicare covered benefit.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 H2011 is not supported in the record. Specifically, CPT code H2001 is not a Medicare covered benefit. Based on this information, we decided that Medicare rules for coverage of the crisis intervention have not been met.Therefore, we decided that the Plan does not have to pay forcrisis intervention (H2001) provided on February 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the golf membership fee provided on December 26, 2019.You asked the Plan to pay forthe golf membership fee. The Plan denied your request. The Plan says that this is not a covered benefit.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says that membership-based facilities such as spas, golf clubs, or country clubs do not qualify for reimbursement, even if the facility includes gym access.The Plan's rules for coverage of gym benefits have not been met because golf clubs or country clubs do not qualify for reimbursement.Therefore, we decided that the Plan does not have to pay forthe golf membership fee provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 to the enrollee by an out-of-network provider on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora pneumatic compression device (HCPCS E0651 and HCPCS E0667) provided to the enrollee on April 30, 2019.You asked the Planto pay forthe device. You say that this should be paid for.The Plandenied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of the denied codes is:HCPCS E0651:Pneumatic compressor, segmental home model without calibrated gradient pressureHCPCS E0667:Segmental pneumatic appliance for use with pneumatic compressor, full leg 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 device. Our reviewer says that the service at issue in this case were supported by the records. Our physician reviewer found while the documentation indicates that a package was delivered on 5/2/2019 or 5/3/2019, there is no evidence of what was in the package. Therefore, there is no evidence to support that the items that were billed are the items that were delivered/received.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 Plandoes not haveto pay fora pneumatic compression device (HCPCS E0651 and HCPCS E0667) provided to the enrollee on April 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 4, 2019 to June 6, 2019.
You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the treatment authorization code is missing. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 4, 2019 to June 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 31, 2019. You asked the Plan to pay for home health services. You say that you would like reconsideration because you believe this claim denied in error. The Plan denied your request. The Plan says the claim must be billed with a valid HIPPS code, a valid 18-digit Treatment Authorization Code, correct type of bill and valid 5-digit CBSA code. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on November 9, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 laboratory testing at issue in this appeal 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 the
laboratory testing provided on November 9, 2019.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approve the repeat echocardiogram. We decided that the Plan does not have to pre-approve the nuclear stress test. You asked the Plan to pre-approve the requested services. You say that this is medically necessary. The Plan says that there are no exam findings of murmur or lower extremity edema, and no documentation of valvular disease requiring routine surveillance.

We decided that the Plan has to pre-approve the repeat echocardiogram. 

The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for the repeat echocardiogram. the repeat echocardiogram. Our reviewer says that this request is medically reasonable and necessary. Our physician reviewer found that the enrollee had an echocardiogram in 2018 with aortic dilation. In this circumstance, a repeat study about two years after the prior exam to reassess aortic enlargement is reasonable and appropriate according to accepted guidelines.

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 repeat echocardiogram have been met. Therefore, we decided that the Plan has to pre-approve the repeat echocardiogram. 

We also decided that the Plan does not have to pre-approve the nuclear stress test.

The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered when specific indications are noted.

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 for the nuclear stress test. Our reviewer says that the requested test is not medically reasonable or necessary. Our physician reviewer found that there are no documented anginal-quality symptoms, no documented abnormal cardiovascular physical exam findings, and no documented ischemic electrocardiographic findings. In the absence of anginal symptoms or electrocardiography changes the records do not support the medical necessity for nuclear stress testing. Coverage criteria for nuclear stress testing are not met since there are no covered indications for the procedure.

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 nuclear stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve the nuclear stress test.

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 waive the copayment for the diagnostic colonoscopy provided on
May 26, 2016.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should not be
responsible for the copayment for the colonoscopy with biopsy. The Plan denied your request. The Plan says
you have been charged the correct cost sharing 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 $250
copayment for each visit for surgical procedures, including but not limited to cardiac catheterizations,
angiogram, endoscopy, epidural injections, and non-screening colonoscopies.
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy
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 the diagnostic colonoscopy provided on May 26, 2016.
Your complaint that it is fraudulent to receive a bill after four years of the service 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns for tooth #'s 21 & 28.You asked the Plan to pre-approvethe crowns. The Plan denied your request. The Plan says the service is not medically necessary. The Plan also says that there does not appear to be sufficient loss of tooth structure to meet requirements for approval.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 necessaryand 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 pre-approve the crowns. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation provided was not sufficient to determine if the criteria for coverage for crowns for teeth #'s 21 and 28 have been met.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 pre-approvecrowns for tooth #'s 21 & 28.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided by PROVIDER on January 1, 2020.You asked the Plan to waive the copayment foran ambulance trip. You say that you do not agree with this copayment.The Plan denied your request. The Plan says the correct copayment has been applied.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 $250 copayment for ambulance services. The enrollee has been asked to pay a $250 copayment for an ambulance trip. The correct copayment has been applied to the service that was provided. An ambulance trip falls within the ambulance services 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 foran ambulance trip provided by PROVIDER on January 1, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 9, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because this was a follow-up visit. 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 $50 copayment for each specialist visit. You received a specialist visit on September 9, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression and fusion surgery.
You asked the Plan to pre-approve the lumbar spine surgery. You say that you feel that this surgery should be approved. The Plan denied your request. The Plan says the records provided do not show any issues for which surgery is warranted at this time. Imaging shows some lumbar spine issues but the records do not document low back symptoms.
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 lumbar spine surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal surgery are not met. There is no documented spine instability. There is no correlation between imaging and exam findings. 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 lumbar spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression and fusion surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 30, 2019 to February 1, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says that the enrollee could have been treated in observation.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 record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. The patient presented to the emergency department and stated that her symptoms started about two weeks ago with left hand discomfort and swelling. She was admitted and observed overnight with supportive management.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 January 30, 2019 to February 1, 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab Hycela.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found Rituximab Hycela is not FDA-approved for the treatment of Wegener's granulomatosis with renal involvement. The use of Rituximab Hycela for the treatment of this medical condition is not supported in the compendia or in the medical literature. The drug is therefore not reasonable or medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab Hycela.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from November 6, 2019 through November 24, 2019 and November 30, 2019 through December 1, 2019.You asked the Plan to pay for SNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from November 6, 2019 through November 24, 2019 and November 30, 2019 through December 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on December 9, 2019 to January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you went to this chiropractor because he is in the same building that you work in. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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