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

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Pelvis (72196).
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says that rules for coverage were not 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 MRI. Our reviewer says that the MRI is medically necessary. Our physician reviewer found the patient has invasive bladder cancer for which he received chemotherapy, as well as an appendiceal carcinoma. MRI of the pelvis is considered an option for surveillance imaging for both of these cancer on a yearly basis and the patient was last imaged in February 2019. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Pelvis (72196).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency services provided on August 28, 2019.
You asked the Plan to pay for the emergency services. You say that the services were medically necessary. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows proof of hospice election from July 23, 2019 to September 20, 2019. Therefore, we decided that the Plan does not have to pay for the emergency services provided on August 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department (ED) visit (99283) provided on January 21, 2019.You asked the Plan to waive the copayment for the ED visit. You say that the services provided do not warrant the $90 copayment.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 copayment for emergency care.You have been asked to pay $90 for the ED visit. An ED visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an emergency department (ED) visit (99283) provided on January 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora platelet plasma injection (0232T), surgical trays (A4550), a propofol injection (J2704) and fentanyl injection (J2704) provided on October 18, 2019.You asked the Plan to pay for the ambulatory surgery center services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed ancillary services are listed on the addendum, but have an indicator listing them as packaged services.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, CPT code 0232T is listed on Addendum AAFinal ASC Covered Surgical Procedures, but the payment indicator is N1 indicating that this is a packaged service and no separate payment will be made. CPT code A4550 is not listed on the Addendum and therefore not an approved service. CPT codes J2704 and J3010 are listed on the Addendum, but have a payment indicator of NI meaning that these are packaged services and not eligible for separate payment. We find that the ambulatory surgical center servicesare not supported in the record. Based on this information, we decided that Medicare rules for coverage of the ambulatory surgery center services have not been met.Therefore, we decided that the Plan does not have to pay fora platelet plasma injection (0232T), surgical trays (A4550), a propofol injection (J2704) and fentanyl injection (J2704) provided on October 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on September 22, 2019.You asked the Plan to pay forthe ambulance service.You say that the Plan should pay this claim.The Plan denied your request. The Plan says the enrollee was inpatient hospital status at the time of the transport.Medicare does not pay separately for ambulance services to transport a hospital inpatient to another facility for diagnostic tests or special treatment.We looked at the file and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the ambulance service have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance service provided  on September 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on July 9, 2019by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained.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 forskilled nursing services provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visits provided on October 7, 2019 and October 8, 2019.You asked the Plan to waive the copayment forthe ER visits. You say that you had to take two trips to the ER because your feeding tube was not replaced properly. You say that the copayments should be dismissed.The Plan denied your request. The Plan says the copayments 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 copayment for emergency care.You have been asked to pay a $90 copayment for each ER visit. The total amount you owe is $180 ($90/visit x 2 visits = $90). The ER visits 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 forthe ER visits provided on October 7, 2019 and October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the endoscopic procedures provided on September 18, 2018.You asked the Plan to waive the deductible for the endoscopic procedures. You say that the records for the procedure should be reviewed. You say that additional amounts owed should be paid.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $1,000, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network surgery services. This cost sharing is a contractual obligation that had not been met at the time the endoscopic procedures were received on September 18, 2018.Therefore, we decided that the Plan does not have to waive the deductible for the endoscopic procedures provided on September 18, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) and the prefabricated post and core in addition to a crown (D2954) provided on September 20, 2019.You asked the Plan to pay for the dental services. You say that you need the core build up in order get crowns for your teeth. You say that the teeth that you received the core build up and crowns for are the teeth that hold your partial denture. You say that without your partial denture, you are not able to eat. You say that your health is deteriorating without a proper diet. You also say that you are on a limited income which does not allow you to pay for the dental work.The Plan denied your request. The Plan says the annual maximum of $3,000 has been 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum of $3,000 has been exhausted. Therefore, we decided that the Plan does not have to pay forthe core build up (D2950) and the prefabricated post and core in addition to a crown (D2954) provided on September 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve decompression and fusion L2-L3, and decompression of L5-S1.You asked the Plan to pre-approve the lumbar surgery. You say that this is a necessary surgery.The Plan denied your request. The Plan says decompression and fusion has been approved only at L3-L4. The documentation does not support that the other requested procedures are 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 lumbar surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient's MRI from March 2020 does not show any evidence of severe stenosis. Also, there is no clearly documented failure of fusion of instability of the spine. There is no clear documentation of smoking cessation for 3 months. Criteria for spine fusion and decompression surgery are not met.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 lumbar surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve decompression and fusion L2-L3, and decompression of L5-S1.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from October 4, 2019, to November 27, 2019.
You asked the Plan to pay for the services. You say that this was the best plan of action for your cancer. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from October 4, 2019, to November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO) (L3962) and cervical orthosis (L0180) provided May 30, 2019.You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no claim on file for a provider that would have requested this DME or a claim, or the claim on file where this equipment would have been requested is for a provider exam that was not conducted in-person.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) ora rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forthe shoulder, elbow, wrist, hand orthosis (SEWHO) (L3962) and cervical orthosis (L0180) provided May 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are qualified in-network doctors who can provide the care you need.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 medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (CPT 96601) provided to the enrollee from October 3, 2019 to October 19, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says this is an invalid procedure code for this service.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 99601 is "Home infusion/specialty drug administration, per visit (up to 2 hours)."We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of I according to the National Physician Fee Schedule. This is means that the code is not valid for Medicare purposes. 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 pay for infusion services (CPT 96601) provided to the enrollee from October 3, 2019 to October 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor
You asked the Plan to pre-approve the requested device. You say that the enrollee's blood pressure often fluctuates, and she might have white hypertension. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ambulatory blood pressure monitoring is only covered under certain medical indications. 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 requested device. Our physician reviewer found that there is no evidence the enrollee may have white-coat hypertension. The enrollee had elevated office blood pressure readings, but normal out-of-office blood pressure readings. Therefore, the requested home monitor is not shown to be currently medically necessary, reasonable or coverable. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to enrollee on October 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 the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered to enrollee on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bathtub lift for the enrollee. You asked the Plan to pre-approvea bathtub lift. The Plan denied your request. The Plan says the bathtub lift is not primarily medical in nature.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 would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea bathtub lift for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy No Coding test strips for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that a non-preferred meter and test strips for self-monitoring of blood glucose can be covered if deemed medically necessary for the member by a healthcare provider.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 these services. Our reviewer says that the Prodigy No Coding test strips are not considered medically reasonable and necessary in this case. The enrollee has Type 2 diabetes. The requested test strip brand is not listed as a preferred brand per the patient's plan. Submitted medical records do not support the noted the requirement for the non-preferred brand test strips: adaptations for dexterity and visual impairment. Without the support of the documentation, medical necessity cannot be determined. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Prodigy No Coding test strips for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that home health care is not available. The Plan denied your request. The Plan says the 100-day benefit limit has been met.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from December 12, 2019 to April 7, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.