Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020 x2), lenses (V2100 x2), and miscellaneous vision items (V2799 x2) purchased on November 3, 2020.
You asked the Plan to pay for frames, lenses, and miscellaneous vision items. You say that you thought your eyewear benefit changed in September allowing for the allowance to be available. The Plan denied your request. The Plan says the maximum benefit has been exceeded for the calendar year.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames, lenses, and miscellaneous vision items have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $300 on May 15, 2020. Therefore, we decided that the Plan does not have to pay for frames (V2020 x2), lenses (V2100 x2), and miscellaneous vision items (V2799 x2) purchased on November 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.
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 an MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that detailed documentation is not evident regarding any progressive symptoms. Objective findings do not corroborate any neurological deficits. X-rays do demonstrate degenerative changes. The provided documentation does not indicate invasive procedures being requested or discussed at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a femoral fracture (27244) provided on
February 23, 2020.
You asked the Plan to pay for the treatment of a femoral fracture. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation does not
support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 27244 is treatment of intertrochanteric, peritrochanteric,
or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage.
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 treatment of a femoral fracture. Our
reviewer says that the operative note indicates that the enrollee had a procedure on February 24, 2020. A bill
was submitted was submitted for services rendered on February 23, 2020. Our physician reviewer found the
documentation submitted does not support the services rendered on February 23, 2020.
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 treatment of a femoral fracture have not been met. Therefore, we decided
that the Plan does not have to pay for the treatment of a femoral fracture (27244) provided on February 23,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you feel you are not ready to be released. You also say that you still have mobility issues and cannot transfer from chair to bed on your own. The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs. The Plan says that you do not need daily therapy or skilled nursing services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on January 6, 2021.
You asked the Plan to pay for the shingles vaccine. The Plan denied your request. The Plan says this vaccine is
not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on
January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the CT scan provided on December 30, 2020.

You asked the Plan to waive the co-payment for the CT scan. You say that you go for a lung cancer screening every year and never received a co-payment. You say that you were scheduled for a screening and you should not have to pay the co-payment. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 per day for Medicare-covered diagnostic radiology services.

You have been asked to pay $168.92, which is less than the standard $325 co-payment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the CT scan was ordered for diagnostic purposes. 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 co-payment for the CT scan provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program. Medically necessary services can be
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage
(A0425) provided October 15, 2020.

You asked the Plan to pay for the ambulance service. You say that please see attached ambulance report to
show medical necessity. The Plan denied your request. The Plan says the enrollee did not meet the medical
necessity criteria for ambulance transport.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.

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 ambulance service. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case.

Our physician reviewer found the medical records do not support the medical necessity of ambulance services for transport of this enrollee to the hospital. His symptoms reported were chronic and he was hemodynamically stable and alert and oriented x 4 upon arrival of ambulance. He was able to self-ambulate and had no alarming signs or symptoms to require ambulance care for transport. 

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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
from August 11, 2020, to December 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network
services are not covered.
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 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 services provided to you by an out-of-network provider from
August 11, 2020, to December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 20, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that any mammogram is free of charge and you have never paid a copayment for one. You say that you are challenging the copayment. 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 $60 copayment for Medicare-covered x-ray and ultrasounds from an in-network provider.
You have been asked to pay a $60 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic service. The records show the Plan fully paid for the mammogram. 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 ultrasound provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRA provided on January 29, 2021.
You asked the Plan to waive the copayment for the MRA. You say that you are upset with the copayment. 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 20% coinsurance up to $75 per day for Medicare-covered diagnostic radiology services.
You have been asked to pay $75 for the MRA. The MRA falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRA provided on January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
on January 18, 2021.
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 had network providers
available who could have provided 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 services provided to you by an out-of-network provider on
January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 3, 2020.

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 had network providers available who could have provided 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 services provided by an out-of-network provider on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheeler walker (E0143) provided on May 28, 2020, by an OON provider.

You asked the Plan to pay for a wheeler walker. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.

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 a wheeler walker (E0143) provided on May 28, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas treatment and injections (97032, 97150, 97016, 96372, J3490, J3411, J3415, J3490, 99072) provided in a chiropractic clinic on October 8, 2020.
You asked the Plan to pay for Sanexas treatment and injections. You say that this should be covered. The Plan denied your request. The Plan says this cannot be paid as billed.
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 Sanexas treatment and injections (97032, 97150, 97016, 96372, J3490, J3411, J3415, J3490, 99072) provided in a chiropractic clinic on October 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the aspiration and/or injection of fluid from a large joint
(20610) provided on November 26, 2019.
You asked the Plan to hold you harmless for the aspiration. You say that you would like reconsideration
because this procedure was medically necessary in order for you to be able to move your finger. The Plan
denied your request. The Plan says that your provider has been informed that this service was billed incorrectly.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the aspiration by a contract provider. The file does not show that the Plan provided
notice that the aspiration would not be covered. Under Medicare rules, this means the aspiration is considered
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the aspiration and/or
injection of fluid from a large joint (20610) provided on November 26, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office and injection services provided on February 12, 2020.
You asked the Plan to waive the coinsurance for the office and injection services. You say that you have not received a bill for these services prior to and want to know why you are receiving them now. The Plan denied your request. The Plan says the claim was reprocessed on February 18, 2021, to pay according to the Medicare Fee Schedule so that provide would be paid properly for services rendered and the number of units given during your visit for an injection of Gel-One.
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 show that you received office services a Part B medication injection of Gel- One (CPT code J7326) for your bilateral knee osteoarthritis and the office services (CPT Code 99213-25) on February 20, 2020. You were asked to pay 20% coinsurance for the injection and 20% coinsurance for the office visit. Your 2020 EOC states that enrollees must pay 0-20% coinsurance for Medicare Part B prescription drugs and enrollees must pay 0-20% coinsurance for Physician/Practitioner services, including doctor's office visits. 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 coinsurance for the office and injection services provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided on August 4, 2020.
You asked the Plan to pay for the diabetic supplies. You say that the items in dispute were medically necessary. The Plan denied your request. The Plan says they exclusively cover diabetic supplies made by OneTouch/LifeScan.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that plans may specify brands and manufacturers as preferred and may limit the DME to only those preferred brands, as long as the enrollee retains access to all medically necessary items. The contract with the Plan says that the Plan only has to pay for diabetic supplies made by OneTouch/LifeScan unless the enrollee's provider requests and is approved for a medical exception. In this case, the diabetic supplies in dispute were not provided by the Plan's preferred provider. The case file does not show that the items supplied by this non-preferred provider were more medically appropriate than the items that could have been supplied by OneTouch/LifeScan. The case file does not show that prior authorization was requested or approved for an exception to the Plan's preferred provider limitation for these items. We found no exception that would require the Plan to pay for the items supplied by the non-preferred provider. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided on August 4, 2020.