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

We decided that the Plan does not have to pre-approve an MRI of the brain.
You asked the Plan to pre-approve the brain MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says the clinical information does not support that the criteria for coverage have been met.
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 brain MRI. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee suffers from benign positional vertigo with non-specific temporal bone abnormality on CT scan. The vertigo is improved with therapy. Provider ordered MRI to address abnormality on CT. There is no indication in records of a differential diagnosis or reason for MRI scan as problem addressed is improving. As such, this is not considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the brain MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiation services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON radiation care. You say that you were treated by this provider in the past with good results and wish to return to seeing this provider. The Plan denied your request. The Plan says there are in-network providers available who can supply the same service. There is no evidence that there is a clinical situation that cannot be addressed by an in-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 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 provider at issue in this case is not a network provider with the Plan. 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 OON radiation care. Our reviewer says that the requested OON care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has rectal cancer and requested OON radiation care. The enrollee is not currently receiving any active treatment and/or medical management of his/her condition that makes it medically necessary to continue care with this OON provider. There is nothing unique about this enrollee's condition and the plan's network has specialist with the necessary qualifications to meet current standards of care for this enrollee's treatment. 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 OON radiation care have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the OON radiation care. Therefore, we decided that the Plan does not have to pre-approve the radiation services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 10, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's
primary care physician did not refer these services.
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 lab work provided on April 10, 2019 by an out of
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 additional routine transportation trips (A0120).
You asked the Plan to pre-approve the additional trips. You say that you use a walker and is requesting additional transportation as you have no other ways to get to and from your doctor appointments. The Plan denied your request. The Plan says this request exceeds the benefit limitation.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 100 additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the eye photography provided on April 4,
2019.
You asked the Plan to waive the coinsurance for the eye photography. You say that you paid in full at the time
of your appointment and do not feel that you owe any more. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered non-radiological diagnostic services.
You have been asked to pay $4.45 which is 20% of the allowed amount for the eye photography. The allowed
amount is $22.25. ($22.25 x 20% = $4.45). The eye photography falls 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 coinsurance for the eye photography provided on April 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bath tub lift (E1399).
You asked the Plan to pre-approve the bath tub lift. You say that you feel that this should be covered because this you have problems with your knees and hips and cannot lift your legs to get in and out of the shower over the bathtub. The Plan denied your request. The Plan says this is a convenience item and is not covered.
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 the bath tub lift (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you cannot walk without the custom shoe. The Plan denied your request. The Plan says this 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 the requested custom shoe is not part of 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 Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the records do not show that the enrollee's condition
meets the requirements for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services. Our physician reviewer found that the enrollee does require skilled therapy services, but not
on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis
in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services provided from
November 4, 2019 to December 30, 2019
You asked the Plan to waive the copayments for the laboratory services. You say that these charges were done
in error. You say you have had this service multiple times and has never been charged a copayment. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5
copayment for Medicare-covered laboratory services. For each date of service, you have been asked to pay the
allowed amount of the claim because these amounts are less than the $5 copayment for the laboratory services.
You have been asked to pay a $4.37 copayment for the laboratory services on each date of service. The
laboratory services 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 copayments for the laboratory services provided from
November 4, 2019 to December 30, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories and power seat elevation system.
You asked the Plan to pre-approve the power seat elevation system (E2300). You say that the enrollee needs a power wheelchair with a power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories and power seat elevation system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90846) provided on April 8, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services (90846) provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the incontinence supplies because of a medical issue. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided December 20, 2019.
You asked the Plan to waive the copayment for the emergency room services. You say that the copayment should be paid by the auto insurer because this was an accident. The Plan denied your request. The Plan says the correct copayment was charged.
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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall 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 room services provided December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network medical services.. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available who can supply the services needed.
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 not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a bilateral venogram with iliac stenting.
You asked the Plan to pre-approve the venogram with endovenous stenting. You say that the medical records provided support the need for the requested services. The Plan denied your request. The Plan says that the documentation fails to indicate that the enrollee has had conservative treatment.
The Plan follows Medicare rules. Medicare rules say that endovenous stenting is covered for enrollees with certain conditions such as those listed 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 the venogram with endovenous stenting. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the patient has lower extremity edema and venous stasis ulcers that are not healing with conservative therapy and are likely due to venous compression from pelvic malignancy and/or post radiation venous stenosis. In this circumstance restoring venous patency by stenting is reasonable and appropriate. 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 venogram with endovenous stenting have been met. Therefore, we decided that the Plan has to pre-approve a bilateral venogram with iliac stenting.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the thermometer (A4931). 
 
You asked the Plan to pre-approve the thermometer. You say that your doctor advised you to get a thermometer because you were sick with bronchitis for 2 weeks. It is important that you get one to check your temperature because you are afraid of getting COVID. The Plan denied your request. The Plan says this item is not covered because it is a convenience item and is not used to treat a medical condition. 
 
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 the thermometer (A4931).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings. You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings for their varicose veins. The Plan denied your request. The Plan says the compression stockings are not covered when there is no qualifying wound. The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional transportation coverage is necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year. You have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulphate Solution 10mg/5ml.
You asked the Plan to pre-approve the Morphine. You say that you would like reconsideration because this drug is necessary to make the member comfortable. The Plan denied your request. The Plan says this drug is not covered under the member's Medicare Part B Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Morphine Sulphate Solution 10mg/5ml.
Benefits for the Morphine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.