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

We decided that the Plan does not have to waive the copayment for radiation therapy provided from September 30, 2019 to October 21, 2019.
You asked the Plan to waive the copayment for radiation therapy. You say that you were not told there would be a coinsurance for these services. The Plan denied your request. The Plan says these services processed 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 20% coinsurance for radiation therapy. You have been asked to pay a $1,632.40 coinsurance ($8,162.44 total allowed amount x 20% = $1,632.49) for radiation therapy. 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 radiation therapy provided from September 30, 2019 to October 21, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve blepharoplasty.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the records submitted do not support the need for this service.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found upper eyelid blepharoplasty and ptosis repair is medically necessary in this case based on the functional complaints, photos, and physical exam. In this situation, it is clear that the patient has dermatochalasis and ptosis as evidenced by photographs. The physical examination demonstrates MRD less than 2mm that does meet criteria for coverage and is supported by the photographs. The visual fields, history and photographs are compelling evidence of functional disability. 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 been met. Therefore, we decided that the Plan has to pre-approve blepharoplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable daily skilled nursing or daily skilled therapy needs. The enrollee 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve multilevel spinal decompression and fusion for the enrollee.
You asked the Plan to pre-approve multilevel spinal decompression and fusion. You say that this surgery is medically necessary. The Plan denied your request. The Plan says that medical necessity has not been established.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 multilevel spinal decompression and fusion. Our reviewer says that medical necessity for multilevel spinal decompression and fusion has been established. Our physician reviewer found the enrollee in this case has debilitating neurogenic claudication. It is documented that the enrollee has had physical therapy, chiropractic intervention, and epidural steroid injection, as well as narcotics, an inversion table, and heat. An MRI has demonstrated progression of advanced lumber degenerative disease, with nerve root compression. The orthopedic surgeon states that other methods of treatment are inappropriate. The enrollee has been referred to a neurosurgeon. Medical necessity has been established in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of multilevel spinal decompression and fusion have been met. Therefore, we decided that the Plan has to pre-approve multilevel spinal decompression and fusion for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (84484, 99285,
36415, 8005) provided October 19 to October 20, 2019.
You asked the Plan to waive the copayment for the emergency room services. You say that you were told the
copayment would be waived. 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 $120
copayment for Emergency Care.
You have been asked to pay a $120 copayment for the emergency room services. The emergency room services
fall within the Emergency Care benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
emergency room services (84484, 99285, 36415, 8005) provided October 19 to October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 93970 provided on August 27, 2019.
You asked the Plan to pay for CPT code 93970. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says CPT code 93970 was not billed correctly.
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise
code that most fully explains the narrative description of the symptom or diagnosis.
We looked at the file and Medicare rules. The file shows that code 93970 was billed with two or more
mismatched diagnosis codes. The billed diagnosis codes indicate laterality, which is not appropriate for code
93970. CPT code 93970 is a bilateral code; therefore, billing diagnosis codes for both sides is not appropriate.
Therefore, we decided that the Plan does not have to pay for CPT code 93970 provided on August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no required medical services identified that are available at the LTACH, that are not available at the current
health care setting being offered by the health plan. Consequently, the requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that the locations of the in-network
ophthalmologists provided to you by the medical group are too far from your home and they can only perform
simple eye examinations at their office. You could see an in-network provider but found out they are 25 miles
or 40 minutes away from your home. The Plan denied your request. The Plan says your needed service is
available within the network and your condition is not an emergency. You must receive care from a network
provider and in most cases, care received from an out-of-network provider (a provider who is not part of our
plan's network) will not be covered, except for the following: emergency care or urgently needed service and
needed medical care that Medicare requires our plan to cover and the providers in our network cannot provide
this care (authorization is required).
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide an office visit.
Based on the notes received from your doctor, the exam can be done with an in-network provider. You have
been approved for a consult with (eye doctor) instead. Please call the office for an appointment. Please refer to authorization. The record shows that you
are also covered for up to 24 one-way rides per year (75-mile limit each way) when using
contracted transportation providers and when being transported to covered providers and
facilities. Prior authorization rules apply. Under Medicare rules, this means that contract providers are
accessible to you. Therefore, we decided that the Plan does not have to pre-approve an office visit (99204) to
be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there is no reason to think that an intensive rehabilitation therapy program would
significantly impact the enrollee's condition differently compared with therapy provided at a less intense level.
The enrollee's care can be appropriately provided at a skilled nursing facility (SNF) level.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve insertion of anterior segment aqueous drainage device; each
additional device insertion (0376T).
You asked the Plan to pre-approve insertion of anterior segment aqueous drainage device; each additional
device insertion. You say that the service is necessary. The Plan denied your request. The Plan says that based
on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that glaucoma surgical aqueous drainage devices will be
considered medically reasonable and necessary when approved by the FDA and used within accordance of the
FDA-approved/cleared 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 insertion of anterior segment aqueous
drainage device; each additional device insertion. Our reviewer says that the services are medically necessary.
Our physician reviewer found the I-stent inject is a micro-invasive glaucoma (MIGS) procedure in which two
small stents are placed in the trabecular meshwork to facilitate outflow of aqueous. This procedure is
performed in conjunction with cataract surgery. This enrollee has mild open-angle glaucoma and a cataract and
is being treated with an ocular hypotensive medication. Therefore, she meets coverage criteria. This procedure
is medically reasonable for the enrollee in conjunction with cataract surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of anterior segment aqueous drainage device; each additional device
insertion have been met. Therefore, we decided that the Plan has to pre-approve insertion of anterior segment
aqueous drainage device; each additional device insertion (0376T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on January 28, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the orthoses were medically
necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
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) or a 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 noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses
provided on January 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood pressure monitoring provided on September 26, 2019.
You asked the Plan to pay for a blood pressure monitor or blood pressure monitoring during an ambulance
transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory
blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24
hours.
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 A4670 is automatic bp monitor, dial.
We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive
a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately
payable. Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor
or blood pressure monitoring during an ambulance transport have not been met. Therefore, we decided that the
Plan does not have to pay for the blood pressure monitoring provided on September 26,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 6, 2019 by an
out of network provider.
You asked the Plan to pay for the non-emergent ambulance services. You say that the service was medically
necessary. The Plan denied your request. The Plan says you did not request prior authorization for the nonemergent
transport.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the ambulance services provided on September 6, 2019 by an out of network
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided.
You asked the Plan to pre-approve the hearing aids. The Plan denied your request. The Plan says hearing aids are covered by an in-network hearing aid 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. We looked at the file and the Plan's rules. The file shows that the provider is not an in-network hearing aid provider with the Plan. The Plan has an in-network hearing aid provider that can provide the hearing aids. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert system.
You asked the Plan to pre-approve an alert system. You say that the item is necessary. The Plan denied your
request. The Plan says the requested item is not covered. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are a non-covered item.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an alert system have not been met. Therefore, we decided that the Plan does not have to preapprove
an alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on August 19, 2019 and September 30, 2019.
You asked the Plan to pay for the acupuncture treatment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exceeded your allowable acupuncture benefit; therefore, the services are not covered.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, you have exceeded your allowable acupuncture benefit as you have previously received eight acupuncture treatments that were paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on August 19, 2019 and September 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided August 27, 2019.
You asked the Plan to pay for the psychotherapy services. You say that services were medically necessary. The Plan denied your request. The Plan says insufficient information was received to determine if the service at issue should be covered.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The provider made multiple requests for the patient's medical records to support the services billed. No records were provided. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 28, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 28, 2019