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

We decided that the Plan has 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 that 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 the enrollee
previously had an MRI in 2014 that demonstrated multi-level degenerative disease and facet arthropathy, most
pronounced at L4-L5. She underwent injection in January 2021 but continues to have pain radiating to leg with
numbness as well. The repeat MRI is requested to assess disease progression and determine treatment plan. The
requested MRI is medically reasonable and necessary given the enrollee's medical condition.
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 been met. Therefore, we decided that the Plan has to pre-approve
magnetic resonance imaging (MRI) of the lumbar spine.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on October 14, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you thought that all copayments were waived due to COVID-19. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 laboratory tests. You received laboratory tests on October 14, 2020. Laboratory tests are not included in the COVID-19 waiver. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for laboratory tests. Laboratory tests 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 laboratory tests provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 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, a cardiovascular risk assessment panel, 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 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on August 15, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the delivery shows this equipment was purchased, but the claim indicates this equipment was rented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code E0745 is not supported in the record. Specifically, there is a discrepancy within the documentation submitted. The delivery ticket indicates that this equipment was purchased, but the claim was billed with a modifier indicating that the equipment was rented. Based on this information, we decided that Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on August 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 fractions of Proton Beam Therapy Boost.
You asked the Plan to pre-approve the 16 fractions of Proton Beam Therapy Boost. You say that you would like reconsideration because the requested therapy is medically necessary. The Plan denied your request. The Plan says there is no current research showing that the member's type of cancer responds better to the requested type of treatment than the type of treatment the Plan 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 the 16 fractions of Proton Beam Therapy Boost. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a non-proton based intensity-modulated radiation therapy plan would be an accepted standard of care, and proton therapy considered necessary when an IMRT plan cannot meet accepted dosimetric constraints. 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 16 fractions of Proton Beam Therapy Boost have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 fractions of Proton Beam Therapy Boost.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided to the enrollee on October 30, 2020, by an out-of-network provider.
You asked the Plan to pay for the anesthesia services. You say that you are not in-network with the Plan, but you are in-network with Medicare. The Plan denied your request. The Plan says a phone call was made to the enrollee's primary care physician and the services were not referred. The Plan states the services were not referred by a network provider or rendered in a participating facility. The Plan states they 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 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 anesthesia services provided to the enrollee on October 30, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 7, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, the services provided should be billed with code 81479 for the multiple gene assays provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless for the inpatient hospital care provided from January
25, 2021, to January 26, 2021.
You asked the Plan to hold the enrollee harmless for the inpatient care. You say that these services should be
covered because you sent him to the emergency department (ED) for a psychiatric evaluation due to sudden
onset of extreme agitation and aggression in the home. The enrollee continued this aggressive behavior in the
ED and a psychiatric evaluation was requested due to the sudden nature of this change. He was discharged the
following day to a long-term care facility. You believe that this was medically necessary ED care and should be
covered in full. The Plan denied your request. The Plan says that the records show that no urgent medical
condition was found on examination. Due to no severe medical issues, there was no medical reason for
inpatient hospital admission.
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. The Plan is also required to submit all relevant information to the IRE for review.
In this case, the enrollee presented on the morning of January 25, 2021, due to new onset aggressive behavior.
We find that this is an emergency medical condition which would require evaluation to determine any potential
medical cause and to provide treatment. The enrollee was formally admitted as an inpatient by the contracted
hospital the night of January 25. There is no evidence that the enrollee or family was informed via a signed
written notice that there would be no coverage for the services being provided. It appears that the enrollee was
evaluated again in the morning of January 26 and deemed stable for discharge, which ultimately did occur that
same day. Without any clear documentation that the enrollee/caregivers were duly informed that the enrollee
was being admitted to a noncovered hospital stay, and agreed to be held liable for the services, we find that the
inpatient hospital stay is considered approved by the Plan. Therefore, we decided that the Plan has to hold the
enrollee harmless for the inpatient hospital care provided from January 25, 2021, to January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by a tertiary provider.
You asked the Plan to pre-approve the requested services. You say that you need the services in order to have cancer treatment scheduled. The Plan denied your request. The Plan says the required services do not necessitate a tertiary level of 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is a tertiary care network provider with the Plan. The file does not show that your condition requires and advance level of care. The Plan has community-level network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by a tertiary provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the requested procedure is experimental.
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 Vertiflex Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to determine its 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 the Vertiflex Superion Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography angiography (CTA) abdominal aorta and bilateral iliofemoral lower extremity runoff
You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the documentation did not include physical exam results, detailed history, prior picture studies or ankle brachial index to show why requested study is needed.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CTA. Our reviewer says that the documentation does not support the medical necessity of the study in question. Our physician reviewer found the documentation does not describe any issue with respect to the abdomen or lower extremities. There is no documentation in the medical records provided that the CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff was even being considered or requested. 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 CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography angiography (CTA) abdominal aorta and bilateral iliofemoral lower extremity runoff
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic CGM (K0554) and supplies for a CGM (K0553) provided on December 11, 2020.
You asked the Plan to pay for a therapeutic CGM and supplies for a CGM. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery indicates a need for a signature. The document is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a therapeutic CGM (K0554) and supplies for a CGM (K0553) provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the
enrollee on June 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not
supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS
G0482) provided to the enrollee on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on January 7, 2021.

You asked the Plan to pay for the preventive procedure. You say that you were not told that this would be your responsibility. The Plan denied your request. The Plan says this service 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive procedure provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings provided on December 18, 2020.

You asked the Plan to pay for the scalings and planings. You say that you contacted the Plan on December 7, 2020 advising that you wished to make a payment. You also say that you were not advised that your membership had been terminated as of December 1, 2020. The Plan denied your request. The Plan says you were sent multiple letters advising you that your plan premium was overdue, and if you did not make payment that your membership would be changed. The Plan also says that your dental coverage was terminated beginning December 1, 2020 due to the premium not having been paid by November 30, 2020.

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 because your dental benefit was terminated beginning December 1, 2020. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings provided on December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthroplasty provided from October 6, 2020, to October 7, 2020.
You asked the Plan to waive the copayment for arthroplasty. You say that you were told that you would only owe a $125 copayment and feel that the way the services were billed is unfair. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received arthroplasty on October 6, 2020, to October 7, 2020, at an outpatient hospital facility. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for arthroplasty. Arthroplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthroplasty provided from October 6, 2020, to October 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional PT visits.
You asked the Plan to pre-approve the four (4) additional PT visits. The Plan denied your request. The Plan says an additional four (4) PT visit are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 four (4) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been authorized additional therapy, which can ensure instruction and review of a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.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 four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits.