Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IMRT.
You asked the Plan to pre-approve IMRT. You say that you would like reconsideration because IMRT is being requested to relieve the member's pain. The Plan denied your request. The Plan says there is no current research showing that your type of cancer responds better to the requested type of treatment than the type of treatment we can approve.
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 IMRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not provide a clear dosimetric rationale for the need of IMRT, which would be needed when offering IMRT for non-standard indications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve IMRT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on December 3, 2020.
You asked the Plan to pay for the dental services. You say that you did not know that the provider was out of network. You also say that if you knew that the provider was out of network, you would have gone to an in network provider. The Plan denied your request. The Plan says the provider in this case was out of network on the date of service. The Plan says that dental services that you receive out of network 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, dental services that you receive out of network are not among those covered under this benefit. The record shows that the provider in this case did not become in network with the Plan until December 31, 2020, after you received the services. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on December 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (C8929) routine electrocardiogram (ECG) with at least 12 leads (93000) provided October 6, 2020 to October 15, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you disagree with your cost sharing amount for the services rendered. The Plan denied your request. The Plan says the claims were processed, and the correct copayment was applied per the Evidence of Coverage.
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 $25 for Medicare covered non-radiological diagnostic services. You have been asked to pay $43 ($25 + $17.60) copayment for the diagnostic services. If you receive more than one service at an appointment, then you are responsible for the cost share of each service received. On October 6, 2020 you received a nuclear study and an echocardiogram and you are responsible for both services. You had already paid the $105 on the date of service. The EKG has a copay of $25 however, the allowed amount is $17.60. Sine the allowed amount is less than the copay amount you are responsible for the lesser amount. the diagnostic services fall 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 transthoracic echocardiography (C8929) routine electrocardiogram (ECG) with at least 12 leads (93000) provided October 6, 2020 to October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210)
provided August 11, 2020.
You asked the Plan to pay for the complete series of x-rays. You say that the service should be a covered
benefit. The Plan denied your request. The Plan says the frequency limitation for the service has been exceeded
and therefore is 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 service is only covered
once every three years. The case file confirms that the Plan has already covered one full mouth x-ray within
this timeframe. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of
radiographic images (D0210) provided August 11, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided to the enrollee on November 11, 2020.
You asked the Plan to pay for the ambulance services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that ambulance transport to or from an outpatient office is not a
Medicare covered benefit.
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 services. Our reviewer says
that the ambulance services were medically reasonable and necessary for the enrollee. There is documentation
that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle)
were contraindicated for this patient. The patient needed the expertise, services and lifesaving and life-sustaining
equipment that only a fully equipped ambulance can provide for safe transport. The Centers for
Medicare and Medicaid Services due to the COVID-19 pandemic has expanded the list of destinations for
which it covers ambulance transportation to include all destinations, from any point of origin, that are equipped
to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established
by state and/or local laws where the services will be furnished. Our physician reviewer found that the enrollee's
condition met Medicare criteria for the ambulance 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 ambulance services have been met. Therefore, we decided that the Plan has
to pay for the ambulance services provided to the enrollee on November 11, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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. Our physician reviewer found the enrollee was admitted to the current acute care hospital with osteomyelitis and Methicillin-resistant Staphylococcus aureus (MRSA) infection and bleeding of in stage 4 sacral ulcer. The enrollee was treated with antibiotics, wound debridement, but the course was complicated with anemia, hypotension which is more recently stable. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the enrollee does not meet criteria for the requested 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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the cervical cancer screening rendered on December 16, 2020.
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 that you exhausted the benefit limit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that a cervical cancer screening is covered once ever 24 moths and the screening on December 16, 2020 exceeded this benefit limit; however, the Plan has not provided any documentation of your previously covered cervical cancer screening. There is no documentation to support that you had a covered cervical cancer screening within 24 months prior of the date of service. Therefore, we decided that the Plan has to pay for the cervical cancer screening rendered on December 16, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 12, 2020.
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 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 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
services rendered on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus xF testing (81455).

You asked the Plan to pay for Tempus xF testing. You say that this was medically necessary. The Plan denied your request. The Plan says this test does not meet Medicare criteria.

The Plan must follow Medicare rules. Medicare rules say that a non-FDA approved test in the MolDX program it must be an approved/cleared laboratory developed test that has undergone a full technical assessment via the DEX Diagnostics Exchange.

We looked at the file and Medicare rules. To date, the Tempus xF Gene Panel has not undergone the required technical assessment and is therefore not covered by Medicare Based on this information, we decided that Medicare rules for coverage of Tempus xF testing have not been met. Therefore, we decided that the Plan does not have to pay for Tempus xF testing (81455).
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You have a past medical history of neuropathy,
arthritis, chronic pain, and depression. You are living at home with increasing debility and pain. Your medical
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a
different level of care. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found
that your condition does not meet Medicare criteria for IRF care.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on October 20, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told you needed to have this colonoscopy. 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). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery/in-network/outpatient facility visits. You have been asked to pay a $250 copayment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network/outpatient facility 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 diagnostic colonoscopy provided by a participating provider on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy (88305) provided on September 18, 2020.
You asked the Plan to pay for the biopsy. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a biopsy (88305) provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for the hearing aids. 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 when provided by an out-of-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by an in-network provider.

We looked at the file and the Plan's rules. The file shows that the enrollee received hearing aids from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colonoscopy procedure.

You asked the Plan to waive the deductible for the colonoscopy procedure. You say that you did not know you had a deductible for this procedure. The Plan denied your request. The Plan says you were charged the deductible correctly.

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 you have a $1000 deductible.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy procedure. Therefore, we decided that the Plan does not have to waive the deductible for the colonoscopy procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Gel.
You asked the Plan to pre-approve Diclofenac Gel. You say that you would like reconsideration because this
drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under
Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Diclofenac Gel.
Benefits for Diclofenac Gel may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) (72148) provided by an out-of-network (OON) provider on August 18, 2020.
You asked the Plan to waive the deductible for an OON MRI. You say that you should only be responsible for a $180 copayment. The Plan denied your request. The Plan says this processed correctly.
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 $1000 deductible for out-of-network services that are not urgent/emergent, preventative, or supplemental. The item or service you asked the Plan to waive the deductible for is an out-of-network service that is not urgent/emergent, preventative, or supplemental. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for out-of-network services that are not urgent/emergent, preventative, or supplemental. This cost sharing is a contractual obligation that had not been met at the time an OON MRI was received on August 18, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) (72148) provided by an out-of-network (OON) provider on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System.
You asked the Plan to pre-approve a Life Alert System. You say that this is necessary in case you fall. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a telephone alert system will not be covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Life Alert System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life Alert System.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings.

You asked the Plan to pay for the home health/hospice aide services. The Plan denied your request. The Plan says the billed service cannot be verified.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. The enrollee was receiving home health aide services without getting skilled nursing or therapy and this is not covered by Medicare. Also, this provider does not appear to be enrolled in Medicare as a home health agency. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings.