Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745) provided on July 9, 2020.
You asked the Plan to pay for this item. You say that a neuromuscular stimulator was medically necessary. The Plan denied your request. The Plan says the documentation indicates that this item is not necessary for the treatment of the patient's condition.
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 pay for this item. Our reviewer says that the neuromuscular stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had a chief complaint of ankle pain. Diagnoses of primary osteoarthritis of the right and left ankles and feet, pain in the right and left ankles and the joints of both feet, and muscle wasting and atrophy of the right and left lower legs are listed in the exam notes. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator, electronic shock unit was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankles and feet. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 27, 2020.
You asked the Plan to pay for the comprehensive exam (D0150) and full mouth x-ray set (D0210). You say that the services were necessary for a dental crown. The Plan denied your request. The Plan says the benefit limit is one procedure each every three plan years and you had these services on February 19, 2019.
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, you have already reached the benefit limit. Therefore, we decided that the Plan does not have to pay for the dental services provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the adjustable, folding, wheeled walker
(E0143) and the sales tax (S9999).

You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration
of the Plan's denial for payment. The Plan denied your request. The Plan says the walker is not a covered
benefit as it was purchased from a provider that does not participate in the Medicare program.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these items have not been met. Specifically, this item was purchased from a provider that does not
participate in the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement
for the adjustable, folding, wheeled walker (E0143) and the sales tax (S9999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the upper back (72157).
You asked the Plan to pre-approve the MRI. You say that the enrollee's symptoms are new or getting worse. X-ray may show something that needs to be checked further. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a history of chordoma treated with radiotherapy (IMRT + proton boost). Surveillance imaging is necessary. Generally, this would require surveillance imaging to assess for recurrence of the treated lesion. It is unclear why a thoracic spine MRI was ordered for this enrollee. While metastatic progression is possible, metastases can develop at any site, and routine screening for metastases is not an accepted standard of care. No rationale is provided for the need of a thoracic spine MRI. The need for an MRI of the thoracic spine was not provided and it would not be within accepted standards of medical practice to order an MRI of the thoracic spine when a cervical spine MRI will adequately image the spine at risk for recurrence. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the upper back (72157).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing.

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 claim was billed incorrectly.

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 an outpatient rehabilitation
setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to
pay for the drug testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the elliptical purchased on September 5, 2020.
You asked the Plan to reimburse you for the elliptical. You say that you purchased equipment to exercise and stay healthy so you would like to be reimbursed. The Plan denied your request. The Plan says purchases made prior to October 1, 2020 do not qualify.
The rules say that Medicare does not cover exercise equipment. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan benefit period for exercise equipment was October 1, 2020, to December 31, 2020. The Plan's rules for coverage of exercise equipment have not been met because the elliptical was purchased on September 5, 2020, before the benefit period. Therefore, we decided that the Plan does not have to reimburse you for the elliptical purchased on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the x-ray exam of the heel (73650) and the
walking boot (L4361) provided on September 1, 2020.
You asked the Plan to cover and waive the cost-share for the x-ray and the walking boot. You say that you
were referred to this provider by your primary care provider and did not realize that the doctor you were
referred to was out-of-network. The Plan denied your request. The Plan says that the services will be covered
since you had a referral, but an in-network provider must be used going forward. However, some of the
provided services still have cost-sharing responsibilities even when provided in-network.
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 x-ray exams and 20% coinsurance for DME and related supplies.
You have been asked to pay a $20 copayment for an x-ray exam and 20% coinsurance for a walking boot. The
Plan's allowed amount for the walking boot is $293.96 ($293.96 x 20% = $58.79). The walking boot falls
within the DME and related supplies benefit category. This means that you have been asked to pay the correct
amount for both services 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
cost-share for the x-ray exam of the heel (73650) and the walking boot (L4361) provided on September 1,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
You asked the Plan to pay for neuromuscular stimulator. You say that the services provided were medically necessary for the enrollee. The Plan denied your request. The Plan says the services were not reasonable and necessary for the enrollee's condition.
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 pay for neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the ankles and feet. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation services rendered on October 8,
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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that the rendering provider name and identifiers are
required for billing of Form CMS 1450.

We looked at the file and Medicare rules. The file shows that the claim was billed with the incorrect provider
taxonomy. 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 pay for the electrical stimulation services
rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 20, 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 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional HH skilled nursing visits (G0299).

You asked the Plan to pre-approve the additional HH skilled nursing visits. The Plan denied your request. The Plan says the criteria has not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional HH skilled nursing visits. Our reviewer says that the additional skilled nursing services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. Our reviewer found that the enrollee does not require skilled nursing to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration.  Our physician reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 additional HH skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional HH skilled nursing visits (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0150, D0274, D1110) provided by an out-of-network (OON) dentist on October 24, 2020.

You asked the Plan to pay for OON dental services. You say that you are comfortable with this dentist and he accommodates you with evening and Saturday appointments. The Plan denied your request. The Plan says out-of-network dental 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, out-of-network services not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D0274, D1110) provided by an out-of-network (OON) dentist on October 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99203), therapeutic activities (97530), and the therapeutic exercises (97110).

You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99203), therapeutic activities (97530), and the therapeutic exercises (97110).
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 for the enrollee.

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 the enrollee can safely receive the services needed 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 above. 

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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and diverticultis with abscess. Sigmoid colectomy and colostomy was performed. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility services. You say that you would like reconsideration because it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says utilization of network providers is required when possible and 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 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 medical services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tangential biopsy of single skin lesion.
You asked the Plan to waive the copayment for the biopsy. You say that the biopsy was performed in an office setting. The Plan denied your request. The Plan says the service you received was outpatient surgery, therefore the correct cost share 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 $350 copayment for outpatient surgery. You have been asked to pay a $215.04 copayment for the biopsy, which is an amount less than the $350 copayment amount outlined in your EOC. The biopsy 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 for the tangential biopsy of single skin lesion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on June 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychiatric services. You say that you go to Idaho in the summer. You say that you called and verified that you could get your medication out-of-network. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that medication is covered; this does not include unauthorized office visits provided by an out-of-area/out-of-network provider.
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 psychiatric services provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the cost is too expensive. The Plan denied your request. The Plan says the correct cost-share amount 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). The enrollee's contract with the Plan clearly says that they must pay a $350 copayment per day for days 1-5, and $0 after day 5 for inpatient hospital care. The enrollee has been asked to pay a total of $1750 ($350 per day) in copayments for days 1-5 of your inpatient hospital stay. The inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation they agreed to pay when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay.