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

We decided that the Plan does not have to provide a home blood pressure monitor.You asked the Plan to provide a home blood pressure monitor. You say that your primary care physician requires you to monitor hour blood pressure regularly.The Plan denied your request. The Plan says medical records do not show you are on dialysis at home.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to provide a home blood pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. The Plan denied your request. The Plan says that this is not a covered benefit because it is not primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approveapower seat elevation feature for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the in-network exception. You say that you would like reconsideration because your follow up appointment is not scheduled until later in the year.The Plan denied your request. The Plan says there is no medical need for an additional transition of care period.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the in-network exception have not been met. The provider at issue in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the in-network exception.Therefore, we decided that the Plan does not have to pre-approve an in-network exception for medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 10, 2020. You asked the Plan to pay for the x-ray services. 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 supported by the documentation. 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 code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation supports that one (1) unit of this code was provided. This was previously approved and paid by the plan. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital services provided January 1,2019 to January 31, 2019 by an international provider.You asked the Plan to pay forthe hospital services. You say that the services should be covered.The Plan denied your request. The Plan says the provided documentation does not support payment.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The provided documentation was limited to receipts and letters from physicians. No medical records were provided to support that the services provided abroad were emergent in nature. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met.Therefore, we decided that the Plan does not have to pay forhospital services provided January 1, 2019 to January 31, 2019 by an international provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteopathic manipulation you received from October 9,
2019, to November 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only pays
for the alternative medicine services listed in the Evidence of Coverage.
We looked at the file, and the Plan's rules. Osteopathic manipulation is not covered under the Plan's alternative
medicine benefit. 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 the osteopathic manipulation you
received from October 9, 2019, to November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI services provided on June 28, 2018.
You asked the Plan to pay for the MRI services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services must be submitted to the enrollee's primary payer first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insure. As the secondary insurer, the Plan cannot be held responsible for the MRI services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the MRI services provided on June 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy you received from March 1, 2019, to March 26, 2019.You asked the Plan to waivethe coinsurance. The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for radiation therapy. Review of the file shows that you were provided radiation therapy services from March 1, 2019, to March 26, 2019. You have been asked to pay a 20% coinsurance for the services, totaling $1,450.01. The services fall within the outpatient hospital 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 waivethe coinsurance for the radiation therapy you received from March 1, 2019, to March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors.
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 code 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/orpressure monitoring); each hour, Red blood cells, washed, each unit." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the Part A DRG payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 12, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you spoke with plan representatives who said that you should be reimbursed the full amount. The Plan denied your request. The Plan says your claim has been processed correctly in accordance with your plan benefit. The Plan also says that you did not contact the Plan prior to the services being rendered.
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, you are responsible for a 50% coinsurance for non-Medicare covered preventive dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 12, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on November 4, 2019.
You asked the Plan to pay for the dental service. You say that you were advised at your appointment that you needed updated x-rays. You say that you eventually agreed as you haven't had to pay for x-rays in the past. You also say that you would not have had them done if you knew they would not be covered. The Plan denied your request. The Plan says the complete series of x-rays is not 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 dental service you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on November 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve MRI. You say that you are appealing with medical records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the record does not show failure of conservative therapy, progression or worsening symptoms during the course of conservative therapy, or abnormal electromyography (EMG) or nerve conduction studies (NCS).
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 to pre-approve MRI. Our reviewer says that the enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee has chronic lower back pain which is getting worse. Therefore, this request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
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 Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee is not due
for another dose until October 2020.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Prolia. Our physician reviewer found
that the enrollee has a history of osteopenia. It is indicated to increase bone mass in men and postmenopausal
women with osteoporosis at high risk for fracture. Additionally, it is indicated for glucocorticoid-induced
osteoporosis in men and women at high risk of fracture. The general dosage is 60 mg every 6 months. Prolia
was approved, and a claim paid in April 2020.The review has determined that the requested dosing of Prolia is
not FDA-approved for the enrollee's diagnosis. The dosage is not supported by one of the major drug
compendia or by clinical research that appears in a CMS-approved medical journal. The requested dosage is
not indicated, not supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on April 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95861 is not supported.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 code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.We findthat CPT code 95861 is not supported in the medical record. Specifically, there is no documentation of needle electromyography of two extremities with or without related paraspinal areas, was performed. 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 pay forthe testing services rendered on April 15, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from December 3, 2019 to December 31, 2019.
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 hospital services provided from December 3, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weight scale (E1639).
You asked the Plan to pre-approve a weight scale. You say that you are appealing the denial of a scale because
you are not working right now and cannot afford to buy anything. The Plan denied your request. The Plan says
this item is only covered benefit. Medicare rules say that a weight scale is only covered if a person is on
dialysis.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a weight scale (E1639).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 29, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-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 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 you by an out-of-network provider on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered on February 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on February 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization has been 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 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 lab tests provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 25, 2019.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that molecular diagnostic testing for genitourinary
conditions is covered when medically necessary.
We looked at the file and Medicare rules. The file does not contain any documentation to support that the
testing was medically necessary. 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 pay for the laboratory
services rendered on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on February 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on February 5, 2020.