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

We decided that the Plan does not have to pay for outpatient clinic visit for assessment and management of a 
patient (G0463) provided on September 2, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that please find the included medical records 
to support the medical necessity of the services provided to the enrollee in good faith. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 outpatient clinic visit for assessment and 
management of a patient (G0463) provided on September 2, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650) provided on August 6, 2020. 
 
You asked the Plan to pay for the back brace. You say that you would like reconsideration because this back 
brace is medically necessary. The Plan denied your request. The Plan says the records lack an in-person 
assessment information such as range of motion or strength tests. 
 
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 back brace. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an appropriate history and a physical examination of the back would reasonably be required to 
adequately assess whether the coverage criteria for an lumbar-sacral orthosis have been met. The 
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered 
indications in this case, as there is insufficient documentation of a credible physical examination of the back. 
 
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 back brace have not been met. Therefore, we decided that the Plan does not 
have to pay for the back brace (L0650) provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new complete lower limb prosthesis for the enrollee. 
 
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not meet Medicare criteria as reasonable and necessary. 
 
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 prosthesis. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal a functional level of 3 or higher, or that the enrollee will be 
able to reach or maintain the defined the functional state within a reasonable period of time. While the enrollee 
is motivated to ambulate, the documentation does not reveal objective clinical evidence from the treating 
medical provider that indicate K3 microprocessor foot is 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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new complete lower limb prosthesis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids purchased May 27, 2020, from an 
out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for hearing aids. You say that you would like to receive reimbursement 
for the hearing aids. The Plan denied your request. The Plan says there is no benefit for hearing aids purchased 
from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from an in-network provider.  
 
We looked at the file and the Plan's rules. The file indicates that the hearing aids were purchased from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been 
met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids purchased May 27, 
2020, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the tetanus shot services provided on September 5, 2020. You asked the Plan to pay for the services provided. You say that you received a tetanus shot due to a laceration on your scalp. The Plan denied your request. The Plan says that the diagnosis code was not assigned properly. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The records show that you have been injured or directly exposed to an illness related to the services at issue. The services were provided by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. You cannot be held responsible for a coding issue with a contract provider. Therefore, we decided that the Plan has to pay for the tetanus shot services provided on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed provided on November 30,
2019.
You asked the Plan to pay for the semi-electric hospital bed. You say that you would like payment made for the
semi-electric hospital bed. The Plan denied your request. The Plan says that this is not covered under the
Member's contract under any normal circumstances.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who
is not enrolled in the Medicare Program.
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided
that the Plan does not have to pay for the semi-electric hospital bed provided on November 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe emergency room services provided on September 11, 2020.You asked the Plan to waive the copay forthe services provided. You say that you cannot afford the copay.The Plan denied your request. The Plan says per the plan benefits, the copay 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 $90 copay for each emergency room visit. You have been asked to pay a $90 copay for the services provided. The services fallwithin 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 copay forthe emergency room services provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services (CPT 99291) provided on September 18, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that critical care is not a service that is paid on a "shift" basis or a "per day" basis. Critical care service is paid on a time-based service provided on an hourly or fraction of an hour basis. For this reason, the documentation provided by the physician must include the amount of time in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the medical documentation to show the total time spent delivering critical care to the enrollee.Therefore, we decided that the Plan does not have to pay forthe critical care services (CPT 99291) provided on September 18, 2020
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) 
received on June 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not call the 
ambulance. The Plan denied your request. The Plan says you were charged this cost sharing 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 $225 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $220.37 for these 
services. This means that you have been asked to pay less than or equal to 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 ambulance services 
(A0428, A0425) received on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, there is no evidence that the enrollee is having problems swallowing solid foods, 
malabsorption of food, no dysphagia problems, no nasogastric tube or gastrostomy. The review has determined 
that  the enrollee does not meet the criteria for this request. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe protective restoration (D2940) provided on September 22, 2020.You asked the Plan to pay forthe protective restoration. You say that the provider was in network. You say that when everything opened back up, you went for a routine cleaning. You say that this visit was covered. You also say thatyour next visit was denied after seeing the same provider.The Plan denied your request. The Plan says the protective restoration is not listed as a covered service. The Plan also says that any services not listed 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe protective restoration (D2940) provided on September 22, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on December 2, 2019.You asked the Plan to pay forthese 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 office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on December 2, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on November 23, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you feel that the MRI should be 
considered preventative and you should not owe a copayment. 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 $150 
copayment for each advanced imaging service.  
 
You received an MRI on November 23, 2020. An MRI is not considered a preventative procedure. Therefore, 
you are responsible to pay the $150 copayment.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI 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 copayment for 
an MRI provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the requested joint is the source of the pain.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. There are not at least three positive exam findings of SI joint dysfunction present on physical exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The review has determined that the requested sacroiliac joint injection without guidance is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formagnetic resonance imaging (MRI) services (70543, 70553) provided on August 19, 2020.You asked the Plan to pay forMRI services. You say that these procedures are not POS specific.The Plan denied your request. The Plan says these services were billed with an incorrect POS.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. For enrollees who are registered hospital inpatients or outpatients the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place.We find that the billing of these services is not supported in the medical record. Specifically, these services were billed with POS code 22 for outpatient hospital, but the record shows that the enrollee was registered as a hospital inpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of MRI services have not been met.Therefore, we decided that the Plan does not have to pay formagnetic resonance imaging (MRI) services (70543, 70553) provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on July 22, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the LSO is covered when specific criteria 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee's chief complaint was 
chronic pain located in the lower back.  
 
The available documentation in the case file does not support that the requested lumbar-sacral orthosis was 
medically reasonable and necessary. An appropriate history and a physical examination of the back would 
reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The 
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered 
indications in this case, as there is insufficient documentation of a credible physical examination of the back. 
 
 
 
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 pay for the lumbar-sacral orthosis (LSO) rendered on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair for the enrollee. 
 
You asked the Plan to pre-approve the commode. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show confinement to the bed or to the room. 
 
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 commode. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that this enrollee is is confined to a single room, or 
confined to one level of the home environment and there is no toilet on that level, or confined to the home and 
there are no toilet facilities in the home. The requested commode chair is not 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 commode have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a commode chair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on September 28, 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 procedure code 99202 is not supported. 
 
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 99202 is new patient office or other outpatient visit, 
typically 20 minutes. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, the code is for a new patient 
office visit; however, the file shows that the enrollee was previously seen on August 24, 2020 so the new 
patient code does nto apply. 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 office visit 
rendered on September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care, and do not require a transfer to a LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you do not require services at the LTACH that are not already available at thecurrent facility. Our reviewer found that there are no services at the LTACH that you require that are not already available and covered at the current facility. Our physician reviewer also found that transfer to a lower level of care may be considered when appropriate and when treatment had completed.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.