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

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on October 15, 2020.

You asked the Plan to waive the co-payment for the myocardial perfusion imaging. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a myocardial perfusion imaging test on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan.

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 a $300 co-payment for Outpatient diagnostic tests.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Myocardial Perfusion imaging test on October 15, 2020. You have been asked to pay a $300 co-payment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the Outpatient diagnostic tests 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 co-payment for the myocardial perfusion imaging provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services received on January 21, 2021.

You asked the Plan to pay for the services. You say that you don't understand how you are responsible for this balance. The Plan denied your request. The Plan says the claim processed appropriately.

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. Your contract clearly states that you will pay more for out-of-network providers. Therefore, we decided that the Plan does not have to pay for outpatient hospital services received on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the chest x-ray (71046) provided on January 5, 2021.

You asked the Plan to waive the co-payment for the chest x-ray (71046). You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a chest x-ray on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan.

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 a $95 co-payment for basic radiological services provided in an outpatient hospital setting.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a chest x-ray on January 5, 2021. You have been asked to pay an $80.95 co-payment for the chest x-ray (71046), which is less than the contracted $95 co-payment amount. The chest x-ray (71046) falls within the Outpatient diagnostic tests 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 co-payment for the chest x-ray (71046) provided on January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage IV breast cancer and bone metastases. She is HER2 + and had cord compression treated with surgery and radiation but has been off treatment since COVID. The case file indicates that the enrollee has had three previous PET scans. A fourth scan is not the standard of care and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance service (A0427) provided on October 27, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

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 a $220 co-payment for each one way Medicare-covered ground ambulance trip.

You have been asked to pay a $220 co-payment for the one way Medicare-covered ground ambulance trip provided. 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 ambulance service (A0427) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the office visit provided on January 15, 2021.

You asked the Plan to waive the co-payment for the office visit. You say that you were not aware that there would be a charge for calling and asking your doctor a question. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 co-payment for each covered visit or consultation in an outpatient location with your PCP or other primary care provider.

You have been asked to pay a $10 co-payment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you had a telephone visit. 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 office visit provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist services provided on October 13, 2020.

You asked the Plan to waive the co-payment for the specialist services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an echocardiography provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan.

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 a $45 co-payment for services provided in a specialist's office.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an echocardiography provided in a specialist's office on October 13, 2020. You have been asked to pay a $45 co-payment for the specialist services. The specialist services fall within the Physician/Practitioner 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 co-payment for the specialist services provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from
January 27, 2020, through January 31, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided from January 27, 2020, through January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture with interpretation (D0367) and the consultation (D9310) provided on December 22, 2020.
You asked the Plan to pay for the dental services. You say that this was an emergency referral. You say that your dentist referred you to this provider. You say that your dentist believed you had an infection. You also say that this provider had to take the 3D x-ray to see the infection. The Plan denied your request. The Plan says cone beam CT capture with interpretation is not listed as a covered service. The Plan says consultation is not listed as a covered service either.
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 Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture with interpretation (D0367) and the consultation (D9310) provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitoring device.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 pre-approve an automatic blood pressure monitoring device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and does not require transfer.
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 physician reviewer found that the enrollee was admitted to the acute hospital for fever, cough, and malaise. His respiratory condition worsened, and he was intubated. There is continued failing of any ventilator weaning trials. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services 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 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: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment has not been proven to be as effective as standard treatment of sacroiliac joint pain.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation of efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically necessary and reasonable. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
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 a precautionary item that would help you. The Plan denied your request. The Plan says this item is not covered per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that emergency communication systems are statutorily not 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the multiaxial ankle (L5968) and flex walk system (L5981).

You asked the Plan to pre-approve the multiaxial ankle and flex walk system. You say that these requested items are not medically reasonable and necessary. The Plan denied your request. The Plan says the requested prosthetics are not medically necessary as they would exceed your needs.

The Plan follows Medicare rules. Medicare rules say that for the multiaxial ankle (L5968) and flex walk system (L5981) to be covered, you need to be at a functional level of K3.

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 multiaxial ankle and flex walk system. Our reviewer says that the requested prosthetics are not medically reasonable and necessary. Our physician reviewer found you are a 58-year-old male who has requested a new prosthetic leg. A medical progress note on February 4, 2021, states that due to walking longer distances on uneven surfaces you need a prosthetic leg with an advanced foot and ankle. However, the documentation does not support that the patient is at a functional level of K3 that would satisfy the criteria listed in the LCD for the multiaxial ankle and flex walk system.

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 multiaxial ankle and flex walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve the multiaxial ankle (L5968) and flex walk system (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested vision provider.
You asked the Plan to pre-approve the eyeglasses to be provided. You say that has you have been to at least ten different in-network providers and none have the frame and optical lens that you prefer and could choose from. The Plan denied your request. The Plan says services or items provided by non-Medicare participating providers are not covered.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The requested provider is not a network vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses to be provided have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested vision provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that the enrollee is a good candidate for this procedure, which is considered safe and effective. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 device. Our reviewer says that the requested 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 of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 the physician services provided on August 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine cleaning device.
You asked the Plan to pre-approve CPAP machine cleaning device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this is not a covered device.
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 continuous positive airway pressure (CPAP) machine cleaning device.