Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for health club membership/fitness classes provided from February 3, 2019 through July 3, 2019 at a non-participating facility.
You asked the Plan to pay for the services. You say that you have out-of-network coverage. The Plan denied your request. The Plan says out-of-network health club memberships are not covered under the benefit plan.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Health Plan confirmed the fitness center is not a participating facility. The 2019 EOC clearly states health club membership/fitness classes are covered if received at a participating facility. Your out-of-network benefit only covers at home fitness kits and written health education materials. Since the fitness center is not a participating fitness facility, the claim processed correctly. Therefore, we decided that the Plan does not have to pay for health club membership/fitness classes provided from February 3, 2019 through July 3, 2019 at a non-participating facility.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy.
You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted clinical information does not specify and diagnostic or therapeutic indications for this procedure.
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 endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided you do not have any of the covered indications for this procedure. 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 endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper endoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on April 29, 2019.
You asked the Plan to pay for the ECG. You say that you are not financially able to pay this bill due to living below the poverty line. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an
in-network provider, which requires prior authorization from the plan.
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 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 for an ECG provided on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ABPM (A4670) provided to the enrollee on November 12, 2019.
You asked the Plan to pay for the ABPM. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ABPM have not been met. The ABPM is only covered for suspected white coat hypertension and must be performed for at least 24 hours to meet coverage criteria. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90mm Hg; and3. No evidence of end-organ damage. ABPM is not covered for any other uses. Therefore, we decided that the Plan does not have to pay for the ABPM (A4670) provided to the enrollee on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing exam provided on December 10, 2019.
You asked the Plan to waive the copayment for the hearing exam. You say that you should not owe a copayment for the diagnostic hearing exam as it should be included with the office visit with the doctor. The Plan denied your request. The Plan says you were charged a $30 copayment and you should only be charged $20 for the services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the hearing exam provided on December 10, 2019. You are asked to pay a $20 copayment for the hearing exam. 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 hearing exam provided on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for cochlear implant batteries purchased on November 27, 2019 from a non-participating Medicare provider.
You asked the Plan to pay for the DME. You say that you were reimbursed for batteries in May 2018 and you are requesting reimbursement for this item. The Plan denied your request. The Plan says there was a reimbursement made however, after further review, that claim was paid in error and should have been denied, like this claim currently under appeal. The Plan states Medicare enrollee's must use providers that participate with Medicare for coverage.
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. You used a provider that does not participate with Medicare. 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 cochlear implant batteries purchased on November 27, 2019 from a non-participating Medicare provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional meals.
You asked the Plan to pre-approve nutritional meals. You say that the requested services are necessary since
you are not fully recovered yet. The Plan denied your request. The Plan says based on the medical records
provided, you were under observation status while at the hospital. Therefore, coverage criteria has 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. Based on this information, we decided that Medicare rules for
coverage of nutritional meals have not been met. Specifically, you were under observation status while at the
hospital. Therefore, we decided that the Plan does not have to pre-approve nutritional meals.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac injections.
You asked the Plan to pre-approve the sacroiliac injections. You say that the member's pain is an 8/10 and the previous injection decreased their pain by at least 50%. The Plan denied your request. The Plan says the notes do not include when the same type of shot was done, that the member's pain was relieved by at least 75% and how much easier it was for the member to do things after the last shot.
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 sacroiliac injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 50% improvement for 3-4 weeks after the initial bilateral sacroiliac injection. 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 sacroiliac injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 16, 2019 to November 14, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for 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 pay for the skilled nursing facility (SNF) services provided October 16, 2019 to November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve the pneumatic compression device. You say that the device is medically
necessary. The Plan denied your request. The Plan says there is no provider documentation corroborating
truncal swelling in the physical examination findings. This is required for coverage.
The Plan follows Medicare rules. Medicare rules say that for this type of compression device to be covered,
records must show that the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that
extends past the limits of a standard compression sleeve.
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 pneumatic compression device. Our
reviewer says that rules for coverage are not met. Our physician reviewer found based on the medical records
provided the patient does not meet the requirements for the requested pneumatic compression device.
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 pneumatic compression device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided by a licensed mental health counselor on March 13, 2019 and March 20, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says counselors are not covered by Medicare or your health plan.
The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is not eligible to participate in Medicare. We looked at the file and Medicare rules. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the mental health services provided by a licensed mental health counselor on March 13, 2019 and March 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans provided on September 23, 2019
and October 10, 2019.
You asked the Plan to waive the copayments for CT scans. You say that you disagree with the high 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 a $250
copayment for CT scans.
You received a CT scan on September 23, 2019. Therefore, you are responsible to pay the allowed amount of
$189.98.
You received a CT scan on October 10, 2019. Therefore, you are responsible to pay the $250 copayment.
The total amount you owe is: $439.98.
You have been asked to pay the total copayment amount of $439.98 for CT scans. CT scans 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 CT scans provided on September 23, 2019 and October 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing provided to the enrollee on September 18, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says train of four is considered a bundled procedure, and payment for it is included in the payment for the already approved neuromonitoring.
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 95999 is "unlisted neurological and neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this code is included in the payment for the neuromonitoring, which was already paid for. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing provided to the enrollee on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on
November 11, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee has previously received the same item on November 6, 2019.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. A lumbar orthosis was previously
provided on November 6, 2019. Therefore, we decided that the Plan does not have to pay for lumbar-sacral
orthosis (L0650) provided to the enrollee on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee on November 14, 2019.
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 screening tests are not covered.
The 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, a chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) and an influenza vaccine (90662 and G0008) provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and an influenza vaccine. You say that the enrollee needed these services. The Plan denied your request. The Plan says these 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 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 an office visit (99214) and an influenza vaccine (90662 and G0008) provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 to
December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you have never had a problem with the provider
being covered. The Plan denied your request. The Plan says there was no authorization on file for the services
provided.
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 OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on December 16, 2019 to December 27,
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 17, 2019 through November 24, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 17, 2019 through November 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excessive skin and subcutaneous tissue removal.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a cosmetic procedure.
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 surgery. Our reviewer says that the requested procedure not considered medically reasonable and necessary in this case. Our physician reviewer found you have a suggestion of functional impairment related to excess buttock tissue. However, medical documentation does not support that the patient has undergone typical dermatologic/conservative management of rashes. Specific measures, as well as a time course of treatment, has not been adequately documented. Thus, without adequate documentation of failed reasonable conservative management of any chronic rashes or other functional impairment, a lower body lift may exceed the patient's medical need. Therefore, excessive skin and subcutaneous tissue removal does not satisfy Medicare medically necessary criteria. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve excessive skin and subcutaneous tissue removal.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 3, 2019.
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 G0483 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 G0483 is definitive drug testing, 22 or more classes.
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that
testing of 22 or more drug classes was performed. 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 drug testing rendered on May 3, 2019.