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

We decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.
You asked the Plan to provide coverage for additional routine, non-emergency transportation trips. The Plan denied your request. The Plan says you have already used up all of your transportation benefit of 24 one-way trips in this benefit year.
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 24 one-way 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 provide coverage for additional routine, non-emergency transportation trips.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the bone density scan provided on April 13, 2021.
You asked the Plan to waive the copayment for the bone density scan. You say that you are covered for one Dexa-scan once every 24 months at a $0 copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is no coinsurance, copayment, or deductible for Medicare-covered bone mass measurement. The Plan says you must pay a $135.47 copayment for the bone density scan. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the bone density scan. The record shows the diagnosis code is for an encounter screening for osteoporosis. Therefore, we decided that the Plan has to waive the copayment for the bone density scan provided on April 13, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a need for services with a qualified professional for management of a maintenance program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found additional skilled therapy is not indicated for your condition. There is no documentation to support the additional visits. Based on a review of the records and PT notes, you made some progress, but did not change significantly from visit to visit. The clinical documentation does not support the need for the therapeutic exercises beyond the seven visits provided. The expectation does not exist that ongoing physical therapy will result in the practical improvement in your level of function within a reasonable and predictable period and does not need the service by a skilled therapist. The request for additional physical therapy visits does not meet medical necessity 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture.
You asked the Plan to pre-approve the upper partial denture. You say that you did not receive dentures in 2017. The Plan denied your request. The Plan says payment was made for a complete upper denture on July 26, 2017. As such, this benefit is exhausted.
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. The documentation shows that payment was made toward a denture less than five years prior to this request. As such, this benefit is exhausted at this time. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro powered upper extremity range of motion
assist device (L8702).
You asked the Plan to pre-approve a MyoPro device. You say that the requested item is a medical necessity for
you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested
device is experimental/investigational.
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 a MyoPro device. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that current guidelines designate robotic therapy to be of "uncertain utility compared with dosematched
conventional upper limb exercise therapies" with unproven benefit in the home environment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a MyoPro device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a MyoPro powered upper extremity range of motion assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided April 22, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived as the provider was unable to help. The Plan denied your request. The Plan says the correct copayment was applied.
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 $45 copayment for Medicare-covered eye exams. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the Medicare-covered eye exams 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 office visit (99214) provided April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. You say that this provider is an intensive activity-based recovery center for individuals living with neurological deficiencies and/or mobility limitations and provides the most up-to-date research, modalities and equipment to provide the highest quality of training for the clients. You say that each client will receive one-on-one training with a specialist focusing on activating paralyzed areas and strengthening weakened muscles. The Plan denied your request. The Plan says although physical therapy would be appropriate for this patient who has a history of traumatic brain injury, inability to ambulate and is not to be wheelchair dependent, there is no medical necessity for it to occur at this out-of-network facility.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118) for the enrollee.
You asked the Plan to pre-approve the scooter. You say that the enrollee lives alone and has no one available to assist with activities of daily living. The Plan denied your request. The Plan says there is not medically necessary for all indications.
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 scooter. Our reviewer says that the requested scooter is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided and the current clinical literature, there is no documentation that the knee scooter at issue in this case is medically reasonable and necessary. The safety and efficacy of the knee scooter has not been demonstrated in the Medicare population. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (92215) provided on August 25, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. 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 had network providers available who could have provided 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 physician services (92215) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the physical exams did not show any signs that this injection would be required.
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 there is a lack of documentation to support the diagnosis. There is no imaging in the records. The request is considered 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the benefit covers 24 one-way trips per calendar year and the 25th trip and beyond is not a covered benefit.
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. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan benefit allows for up to 24 one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg injection (J0702) provided on March 26, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 $40 copayment for each specialist visit for Medicare-covered benefits. Additional coinsurance for Part B drugs and DME supplies will apply when these are provided by the physician. Enrollees pay a 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B covered drugs. You have been asked to pay $1.44 (Plan allowed amount of $7.21 x 20% coinsurance) for the Medicare Part B covered drug provided at a specialist visit. Additional coinsurance for Part B drugs and DME supplies will apply when these are provided by the physician. 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 betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg injection (J0702) provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Lite test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate a trial and failure of the alternatives.
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 test strips. Our reviewer says that the requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific medical necessity to the non-formulary brand in this case. The review indicates the requested diabetes test strip is not covered. The covered alternatives include diabetes test strips made by Lifescan (e.g., One Touch Ultra). 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Lite test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on August 9, 2020.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for August 9, 2020 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on August 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary for a diagnosis of chronic pain. The Plan denied your request. The Plan says the height adjustment feature is considered a convenience item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive (80307) and definitive (G0483) drug testing provided on December 11, 2020.
You asked the Plan to pay for the drug testing. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says the POS code reported is not correct.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not support that the sample was taken by the laboratory directly. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive (80307) and definitive (G0483) drug testing provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0108 x5, E0995, E2311, E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 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 accessories. 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, there is no documentation that the enrollee requires the additional requested accessories for the power wheelchair. The provided records indicate that you have 3+ to 4+/5 upper extremity strength and is reported to be modified independent with feeding, grooming, bathing and dressing thus indicating adequate upper extremity strength and function to operate the power options with their own switches, therefore coverage for E2311, E2313, E2377 is not justified. Coverage for E0995 replacement calf pads is not justified as it is a replacement item. Coverage for K0180 x5 is not justified as these are unbundled accessories. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0108 x5, E0995, E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 7, 2021.
You asked the Plan to waive the copayment for the specialist office visit (99213). You say that you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for Physician Services. You have been asked to pay a $40 copayment for the specialist office visit (99213). The specialist office visit (99213) falls within the Physician Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 7, 2021.