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

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical services provided on February
2, 2019 to May 25, 2019 by an out of network (OON) provider.
You asked the Plan to waive the cost share for the out-of-network services. You say that you believed the plan
would notify you if charges were pending. The Plan denied your request. The Plan says the cost share was
applied based on your out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you receive your care from a provider who is eligible to provide services under Original
Medicare.
The requested provider in this case is not a network provider with the Plan. However, you have out-of-network
benefits. 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. We found no exception
that would require the Plan to waive the cost share for these services. Therefore, we decided that the Plan does
not have to waive the cost share for the medical services provided on February 2, 2019 to May 25, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 20, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you reached your maximum out-of-pocket in April. You say that you should not be responsible for the 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 $5 copayment for each covered primary care provider office visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you did not meet your maximum out-of-pocket prior to the office 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 copayment for the office visit provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks 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 preapprovea pneumatic compression device (E0652).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit on October 4, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you did not receive ER services and disagree with the charges.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 an $80 copayment for emergency care. The medical records show that you had an ER visit on October 4, 2019. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay an $80 copayment for an ER visit. An ER visit 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 an ER visit on October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay formolecular genetic hereditary predictive screening testing provided to the enrollee on October 15, 2019.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there are no medical records in the case file that support the medical necessity of molecular genetic hereditary predictive screening testing in this case. Testing which has no proven relation to the management of a medical condition for the health of an enrollee is not a covered Medicare 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 the testing have not been met.Therefore, we decided that the Plandoes not haveto pay formolecular genetic hereditary predictive screening testing provided to the enrollee on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator.
You asked the Plan to pre-approve a bone growth stimulator. You say that a bone growth stimulator is medically necessary. The Plan denied your request. The Plan says according to the x-ray performed in January 2020 there is evidence of healing.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that the serial radiographs separated by 90 or more days confirm that healing had ceased. The office notes state that there is ongoing healing. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Pride Go-Go 3-wheel scooter.
You asked the Plan to pre-approve Group 1 power operated vehicle. You say that you need a scooter because you cannot walk more than a block. The Plan denied your request. The Plan says the assessment shows you use a 4-wheel walker to complete your MRADLs in your home and you want the scooter for outdoor use.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. Medicare does not cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Pride Go-Go 3-wheel scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services needed could be provided in anothersetting.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 admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee iscurrently undergoing treatment at an ACH for lower extremity cellulitis with bacteremia. The enrollee is taking oral antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare needs.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on October 24, 2019.You asked the Plan to pay fora shingles vaccine. You say that this should be covered.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on October 24, 2019.Benefits for a shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the Lower Extremity (73700) provided by onOctober 24, 2019.You asked the Plan to pay forthe CT scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate claim.The Plan must follow Medicare rules. Medicare rules say that duplicate claims will not be covered. We looked at the file and Medicare rules. The claim does not include any modifiers to denote a repeat service. The claim as submitted is a duplicate of a claim already being processed. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pay forComputed Tomography (CT) of the Lower Extremity (73700) provided on October 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on September 11, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe enrollee has no out-of-network benefits.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 rendering 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 1, 2019.You asked the Plan to pay for the physician's services. 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 servicesat 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 physician's services provided on July 1, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepsychological testing services (96130, 96138).You asked the Plan to pre-approvethese services. You say that testing and treatment are medically necessary as the client needs further outpatient treatment due to his anxiety.The Plan denied your request. The Plan says the psychological testing services are not medically necessary.The Plan follows Medicare rules. Medicare coverage rules say that a request for psychological testing services must indicate that there is an individualized treatment plan stating the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goalsfor the patient.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 patient does not meet criteria for coverage of psychological testing services. Our physician reviewer found that this patient suffers from an Anxiety Disorder. The information provided stated the patient suffers from anxiety; however, it is unclear if it is a disorder. This patient has not undergone therapy nor had a psychiatric evaluation performed to evaluate hisanxiety. Based on the review of the medical records provided, this patient does not requirepsychological testing and could be seen by a psychiatrist for a psychiatric evaluation to differentiate symptoms and diagnose this patient.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-approvepsychological testing services (96130, 96138).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 8, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 laboratory services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on September 4, 2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were never in the outpatient hospital or any outpatient facility. You say that the charge should be rescinded as a processing error. 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 $275 copayment for Medicare-covered outpatient hospital and observation services. You have been asked to pay a $275 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient hospital services" benefit category. The records show that the arthrocentesis was billed by the hospital. 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 arthrocentesis provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (CPT Code K0108), for the enrollee.
You asked the Plan to pre-approve the item. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
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 wheelchair component or accessory, not otherwise specified (CPT Code K0108), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a CPAP device and humidifier.
You asked the Plan to pre-approve continued use of a CPAP device and humidifier. You say that you want your CPAP machine to continue being covered with no break. The Plan denied your request. The Plan says the medical records received show criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The record shows you have not had a reevaluation and are not compliant with usage. Based on this information, we decided that Medicare rules for coverage of continued use of a CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a CPAP device and humidifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power operated vehicle.
You asked the Plan to provide a scooter. You say that the enrollee's cane and walker is no longer appropriate due to balance, pain, and fatigue. The Plan denied your request. The Plan says the scooter is not accessible to the bedroom and bathroom.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The enrollee's Home Assessment shows the bedroom and bathroom are not PMD accessible to help the enrollee complete MRADLs. Medicare does not cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an in-home iontophoresis device.
You asked the Plan to provide an in-home iontophoresis device for electric current therapy. You say that you have called the recommended providers and none have the equipment. The Plan denied your request. The Plan says an in-home iontophoresis device is a convenience item and the services are available in office at a network provider.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We looked at the file and Medicare rules. The Plan has confirmed the iontophoresis therapy is available in office. Based on this information, we decided that Medicare rules for coverage of an in-home iontophoresis device have not been met. Therefore, we decided that the Plan does not have to provide an in-home iontophoresis device.