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

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device (22870, 22869). You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. 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. 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 a Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device (22870, 22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Vitamin D testing provided on June 23, 2020.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says preventative vitamin assay and metabolic function tests 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 test at issue in this appealwas requested for screening purposes. Medicare does not cover this test for screening purposes.Therefore, we decided that the Plan does not have to pay forthe Vitamin D testing provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from June 10, 2020 through July 8, 2020.
You asked the Plan to pay for the medical services. You say that the claims should be paid. The Plan denied your request. The Plan says the provider is excluded or debarred from participation in State and Federal health care programs. The Plan must follow Medicare rules. Medicare rules say that if someone is on the LEIE they are not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity. We looked at the file and Medicare rules. This provider is not federally sanctioned. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided the Plan does not have to pay for the medical services provided from June 10, 2020 through July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins when required (D2950) provided on July 10, 2020.
You asked the Plan to pay for the crown and core buildup. You say that you would not have had these services provided if you had not received the approval letter. You also say that these services were done after the approval date because the office was closed for COVID. The Plan denied your request. The Plan says these services are not covered.
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 requested items or services are not among those covered under this benefit. The record shows that these services were approved for December 31, 2019 through June 28, 2020, and you received these services on July 10, 2020 which was after the authorization expired. The Plan also says that you did not elect the Optional Supplemental Dental Services for the 2002 plan year. Therefore, we decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins when required (D2950) provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea TENS unit for the enrollee.You asked the Planto pre-approvethe unit. You say that this is medically necessary.The Plandenied your request. The Plansaysthere has been back pain for two weeks without a history of surgery.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 unit. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did nothave prior surgery and this was not a request for post-operative pain. This is a request for acute low back pain. Therefore, this request is considered not medically reasonable or 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 the unit have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea TENS unit for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on June 25, 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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in the home setting and should have been billed with POS code 12.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean EasyStand glider (E0637).You asked the Plan to pre-approvethe standing glider. You say that the standing glider is medically necessary.The Plan denied your request. The Plan says this item is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that standing tables are not primarily medical in nature and are not covered. We looked at the file and Medicare rules. The EasyStand glider is not a covered item. Based on this information, we decided that Medicare rules for coverage of the standing glider have not been met.Therefore, we decided that the Plan does not have to pre-approvean EasyStand glider (E0637).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram provided on September 22, 2020.
You asked the Plan to waive the deductible for the mammogram. You say that you are being charged a second mammogram because they are saying it is diagnostic. You say you feel you should not have to pay for the second mammogram. 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. Your contract with the Plan says that there is a $750 deductible that applies towards the mammogram.
The mammogram you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the mammogram. The record shows the second mammogram was done due to left breast asymmetry which makes it diagnostic in nature.
This cost sharing is a contractual obligation that had not been met at the time the mammogram was received on September 22, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the mammogram provided on September 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approvemyocardial perfusion imaging for the enrollee.You asked the Planto pre-approvethe imaging. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe records do not indicate any cardiac symptoms, such as chest pain, shortness of breath, shortness of breath with exertion, palpitations, dizziness, or weakness.The Plan must follow Medicare rules. Medicare rules say that myocardial perfusion imaging can be covered under certain specific indications.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 imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple risk factors for coronary artery disease, including diabetes, hypertension and hyperlipidemia. He also carries a diagnosis ofestablished symptomatic peripheral vascular disease. His EKG shows a right bundle branch block at baseline. 
Though traditionally RBBB has not been associated with increased cardiovascular mortality, more recent studies have questioned this assumption and have shown some correlation. given the relatively high pre-test probability of CAD based on co-morbidities and risk factors along with the abnormal baseline EKG, an ischemic assessment even in the absence of clear cardiac symptoms is warranted especially since the patient is described as having limited exercise capacity. A Lexiscan chemical nuclear stress test is therefore reasonable, medically necessary and appropriate in this instance and would meet the CMS guidelines for medically necessity especially with the abnormal baseline EKG 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 imaging have been met.Therefore, we decided that the Planhas to pre-approvemyocardial perfusion imaging for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen 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 copayment fordiagnostic eye exam with ophthalmologist (92004) provided on September 30, 2020.You asked the Plan to waive the copayment fordiagnostic eye exam. You say that the services should be covered.The Plan denied your request. The Plan says the cost share was 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 $20 copayment for an eye exam to diagnose and treat diseases and conditions of the eye for vision care. You have been asked to pay a $20 copayment for an eye exam to diagnose and treat diseases and conditions of the eye for diagnostic eye exam. This service falls within the vision care 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 fordiagnostic eye exam with ophthalmologist (92004) provided on September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee continues torequire acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography provided on September 30, 2020.You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 servicesat 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 mammography provided on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to waive the copayment foran esophagogastroduodenoscopy (43235) provided on September 24, 2020.You asked the Plan to waive the copayment foran esophagogastroduodenoscopy. You say that this should be covered at no cost.The Plan denied your request. The Plan says while your colonoscopy was covered at no-cost, the esophagogastroduodenoscopy is an outpatient surgery with a copayment.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 outpatient surgery.You have been asked to pay a $250 copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy falls within the outpatient surgery 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 foran esophagogastroduodenoscopy (43235) provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat cushion, back cushion, elevating leg rests, manual recline, battery charger, and seat belt for a power wheelchair (PWC).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. Services that do not serve a purpose that is primarily medical in nature 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested seat cushion and back cushion exceed the enrollee's medical needs. There is no evidence of apressure ulcer or that the he is at a high risk for pressure ulcer or is unable to weight shift. The approved PWC has a captain's chair; therefore, the additional cushions are not medically necessary.There is no evidence of a  musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee or significant edema of the lower extremities that requires an elevating legrest. The enrollee does not require a manual fully reclining back option, as she is not at high riskfor development of a pressure ulcer and is not unable to perform a functional weight shift. She does not use an intermittent catheterization for bladder management and is not unable to independently transfer from a wheelchair to a bed. The elevating leg rests and manual recline are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat cushion, back cushion, elevating leg rests, and manual recline have not been met. The requested battery charger and seat belt are items that do not serve a purpose that is primarily medical in nature. Medicare does not cover these items.Therefore, we decided that the Plan does not have to pre-approvea seat cushion, back cushion, elevating leg rests, manual recline, battery charger, and seat belt for a power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT) scan of the chest (71250) provided on January 17, 2020.You asked the Plan to waive the copayment forthe CT scan of the chest. You say that you would like this copayment waived.The Plan denied your request. The Plan says the copayment processed correctly in this case.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 Medicare-covered diagnostic radiology services. You have been asked to pay a total cost share of $131.37 for the CT scan of the chest ($131.37 allowed amount which is less than the required $250 copayment). The service provided falls within the Medicare-covered diagnostic radiology 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 waive the copayment forthe computed tomography (CT) scan of the chest (71250) provided on January 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance response and treatment with no transport (A0998) provided on September 2, 2020.You asked the Plan to pay forthe ambulance response and treatment with no transport. You say that the service provided was medically necessary.The Plan denied your request. The Plan says without ambulance transport there is no payable service.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance response and treatment with no transport (A0998) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care provided to the enrollee on July 31, 2020, by a non-participating provider.You asked the Plan to pay forthe wound care. You say that emergency wound care was provided in the absence of another contracted/available wound care physician.The Plan denied your request. The Plan says there was no prior authorization for the 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 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 forthe wound care provided to the enrollee on July 31, 2020, by a non-participating provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon August 26, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 physician's services. 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 physician's services provided on August 26, 2020.