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

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on November 26, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you feel as though you should not owe anything for this service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($195.12) is less than your copayment, you are responsible for the full 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 $225 copayment for advanced imaging services. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing for the enrollee.
You asked the Plan to pre-approve this testing. You say that this testing is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met as there is no personal history of
cancer. The Plan must follow Medicare rules. Medicare only covers this testing for those with a previous history of
cancer. The enrollee does not meet these criteria. Therefore, we decided that the Plan does not have to preapprove
BRCA genetic testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Gel-One injection.You asked the Plan to pre-approvea Gel-One injection. You say that a Gel-One injection is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of a Gel-One injection.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Gel-One injection. Our reviewer says that a Gel-One injection is not medically necessary at this time. Our physician reviewer found there is not sufficient evidence in the medical records to support the use of an injection of intraarticular hyaluronic acid of your knee. There are other options other than anti-inflammatory medications that you have not utilized. Furthermore, there is lack of strong evidence in the medical literature supporting the use of hyaluronans for osteoarthritis treatment given lack of benefit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Gel-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approvea Gel-One injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).You asked the Plan to pre-approvea pneumatic compression device. You say that the E0651 device caused additional swelling.The Plan denied your request. The Plan says the E0651 device was not trialed for 4 weeks.The Plan must follow Medicare rules. The rules state that a pneumatic compression device (E0652) is covered when the enrollee has failed a 4 week trial of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.We looked at the file and Medicare rules. Based on this information,we decided that Medicare rules for coverage of a pneumatic compression device have not been met. Specifically, the record does not show a 4 week trial of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided from February 25, 2020 to March 2, 2020. You asked the Plan to pay for the durable medical equipment. 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. 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. 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 the durable medical equipment provided from February 25, 2020 to March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment (81404 and 81406) provided on March 7, 2020.You asked the Plan to pay forthe cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascularrisk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovasculardiseaseThe 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, the cardiovascular risk assessment, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Specifically, Medicare denies coverage for all cardiovascular assessment panels except the basic lipid panel.Therefore, we decided that the Plan does not have to pay forthe cardiovascular risk assessment (81404 and 81406) provided on March 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecustom foot orthotic inserts.You asked the Planto pre-approvethe foot orthotics. You say that you have need of these inserts due to your foot condition.The Plandenied your request. The Plansaysthis item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plandoes not haveto pre-approvecustom foot orthotic inserts.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater services coded 21933 provided on June 23, 2020.
You asked the Plan to pay for the excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 21933 is excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater. We find that CPT code 21933 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of excision, tumor, soft tissue of back or flank, subfascial; 5 cm or greater was performed. The documentation does not support that the excision of the tumor was more than 5cm; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater services have not been met. Therefore, we decided that the Plan does not have to pay for the excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater services coded 21933 provided on June 23, 2020.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
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 preapprove
IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and
necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for syncope earlier in December
2020. She is currently living at home with her family and receiving home health services. Medical conditions
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record does not
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and seat lift mechanism.

You asked the Plan to pre-approve this item. You say that a seat lift chair with mechanism is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 this item. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the records provided do not show a lift chair is part of your doctor's treatment plan. A lift chair will not improve your condition. The records do not show you are incapable of standing from all chairs in the home. Medicare coverage criteria are not met. 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 pre-approve a seat lift chair and seat lift mechanism
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic eye exam (92014) provided on August 8, 2020
by an out of network (OON) provider.
You asked the Plan to pay for the diabetic eye exam. You say that you have received this service in the past
with no charge. The Plan denied your request. The Plan says prior authorization was not obtained by the
facility or the provider; therefore, payment has been correctly denied.
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 has network providers
available who can provide 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 diabetic eye exam (92014) provided on August
8, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ophthalmic imaging provided on March 10, 2020.You asked the Plan to waive the copayment forthe ophthalmic imaging. You say that you were under the impression that the appointment was for a routine eye exam. You say that you were unaware you would receive a copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care.You have been asked to pay a $35 copayment for the ophthalmic imaging. The ophthalmic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Ophthalmic imaging is not considered a routine service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ophthalmic imaging provided on March 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora third level of paravertebral facet joint injections (64495) provided on July 6, 2020.You asked the Plan to pay fora third level of paravertebral facet joint injections. You say that this is supported in the records.The Plan denied your request. The Plan says this service is not documented.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pay for a third level of paravertebral facet joint injections. Our reviewer says that this code is not supported. Our physician reviewer found the operative report supports 2 levels injected, L3/L4 and L5, which the Plan has agreed to pay for. Facet joints are reported by level, not by the nerves innervating that joint.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage ofa paravertebral facet joint injection have not been met.Therefore, we decided that the Plan does not have to pay fora third level of paravertebral facet joint injections (64495) provided on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthoses (L1833, L2397) provided July 15, 2020.You asked the Plan to pay forknee orthoses. You say that the knee orthoses are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the orthoses.The Plan follows Medicare rules. The rules state that a knee immobilizer without joints, or a knee orthosis with adjustable knee joints, or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability.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 knee orthoses. Our reviewer says that the knee orthoses are not medically necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay forknee orthoses (L1833, L2397) provided July 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 10, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you are unhappy with the service
you received. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
care benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July
10, 2020.
We note your complaint that you ate unhappy with the service you received. Your complaint is a grievance that
must be answered by the health plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the sleep study you had on August 2,
2020.
You asked the Plan to waive the coinsurance for the sleep study. You say that you were told that this procedure
wouldn't cost anything. The Plan denied your request. The Plan says you were charged this coinsurance
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for sleep studies.
You have been asked to pay 20% coinsurance for the sleep study. 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
coinsurance for the sleep study you had on August 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 31, 2020 to April 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visits (99214) provided on January 31, 2020, through April 13, 2020.. You say that you would like reconsideration because you have a history with this provider.The Plan denied your request. The Plan says this provider is out-of-network and the services rendered were not urgent, emergent or 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 providerwith the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 31, 2020 to April 13, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe PET scan provided on February 20, 2020.You asked the Plan to pay forthe PET scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services rendered were 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 pay for the PET scan. Our reviewer says that the documentation supports that the PET scan rendered was medically reasonable and necessary. Our physician reviewer found the documentation shows that the services rendered were an initial PET CT for initial treatment strategy for lung cancer. This is a covered indication. Therefore, the enrollee met criteria for the rendered 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 PET scan have been met.Therefore, we decided that the Plan has to pay forthe PET scan provided on February 20, 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 willsend you a letter.