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

We decided that the Plan does not have to pay for the manual therapy techniques (97140) and the chiropractic manipulative treatment (98941) provided by out of network provider from April 16, 2018 to September 23, 2019.
You asked the Plan to pay for these services. You say that you have received care from this chiropractor for several years and your condition has improved greatly. The Plan denied your request. The Plan says you must receive your care from a network provider. There were no extenuating circumstances making it medically necessary to obtain the services out of network. There were in-network chiropractors available to provide the services.
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 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 manual therapy techniques (97140) and the chiropractic manipulative treatment (98941) provided by the out of network provider from April 16, 2018 to September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair for the enrollee.
You asked the Plan to pre-approve an ultra lightweight manual wheelchair. You say that you have requested a light weight wheelchair because the one provided is heavy and difficult to transport. The Plan denied your request. The Plan says that there is no physician order or provider documentation for your request.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the enrollee's physician has not ordered the ultra lightweight manual wheelchair for the enrollee. The record does not contain a physician order for this item. Therefore, we decided that the Plan does not have to pre-approve an ultra lightweight manual wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area physical therapy services.
You asked the Plan to pre-approve the out-of-area services. You say that you are unable to safely return to the service area with your symptoms. The Plan denied your request. The Plan says the physical therapy services are not urgently or emergently needed.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 out-of-area services. Our physician reviewer found that you have vertigo. The provided records do indicate that the care requested is medically necessary. However, the records do not indicate that it would be unreasonable to delay the services until when you return to the service area. Therefore, the request for out-of-area services is not medically reasonable and 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 out-of-area services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 6, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation does not include an itemized shipping/billing invoice to indicate the specific supplies were delivered to the enrollee. The submitted invoice states the items were shipped to the facility. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter placement in a coronary artery provided on September 19, 2018.
You asked the Plan to waive the copayment for the catheter placement in a coronary artery. You say that you disagree with the charges because the hospital took so long to bill. 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 $400 copayment for each outpatient hospital and observation service. You have been asked to pay a $400 copayment for the catheter placement in a coronary artery. The catheter placement in a coronary artery falls within the outpatient hospital 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 catheter placement in a coronary artery provided on September 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core buildup for tooth #18.
You asked the Plan to pre-approve the core buildup. You say that you need the services to prevent further nerve damage. The Plan denied your request. The Plan says the service is not a covered benefit by Medicare or your plan.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core buildup for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463), an x-ray (73562), an aspiration and/or injection of a large joint or joint capsule (20610), and an injection of triamcinolone acetonide (J3301) provided on September 27, 2019.
You asked the Plan to waive the copayment for a hospital outpatient clinic visit, an x-ray, an aspiration and/or injection of a large joint or joint capsule, and an injection. You say that you went to orthopedics and got an injection in the office. You are getting charged too much. You are getting charged at an outpatient surgical/observation copayment. You were in and out of the office and no surgical center or observation was needed. The Plan denied your request. The Plan says outpatient surgery has a $150 copayment in a hospital outpatient facility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery. You have been asked to pay a $150 copayment for a hospital outpatient clinic visit, an x-ray, an aspiration and/or injection of a large joint or joint capsule, and an injection. These services fall within the outpatient surgery benefit category. Code G0463 is categorized as a hospital outpatient clinic visit. 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 a hospital outpatient clinic visit (G0463), an x-ray (73562), an aspiration and/or injection of a large joint or joint capsule (20610), and an injection of triamcinolone acetonide (J3301) provided on September 27, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve fusion of great toe, removal of hardware, and correction of toe joint deformity.
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 all available conservative treatment did not appear to have been tried.
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 the enrollee is seven months status post first MPJ arthrodesis and hammertoe corrections. You continue to have severe pain. Physical examination reveals recurrence of the digital deformities, and x-rays reveal nonunion of the first MPJ arthrodesis. It is medically reasonable and necessary to revise these recurring digital deformities and nonunion arthrodesis first MPJ. These procedures certainly meet the above mentioned Medicare criteria. Therefore, the requested fusion of great toe, removal of hardware, and correction of toe joint deformity are medically reasonable and 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve fusion of great toe, removal of hardware, and correction of toe joint deformity.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed.
You asked the Plan to pre-approve semi-electric hospital bed. You say that the enrollee would benefit from a hospital bed to have an elevated head to help with her breathing and needed elevation to the foot of the bed to help lower extremity edema. The Plan denied your request. The Plan says a semi-electric hospital bed is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested semi-electric hospital bed is not medically necessary. Our physician reviewer found based on available records, the enrollee does not meet criteria for coverage of the requested semi-electric hospital bed. The records do not support the enrollee requires frequent changes in body position or a need for immediate changes in body position. The enrollee does not require special attachments that cannot be fixed and used on an ordinary bed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the polysomnography services represented by CPT code
95810.
You asked the Plan to pre-approve the polysomnography services represented by CPT code 95810. You say
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the
requested 95810 duplicates the diagnostic portion of the approved split night study and is inclusive in the
services provided by the approved 95811 code.
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 95810 is Polysomnography; age 6 years or older, sleep
staging with 4 or more additional parameters of sleep, attended by a technologist.
We looked at the file and Medicare rules. The file shows the Plan has approved coverage of CPT code 95811,
which is defined by the CPT Code Manual as Polysomnography; age 6 years or older, sleep staging with 4 or
more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level
ventilation, attended by a technologist. This approved CPT code includes the services represented in CPT code
95810. Based on this information, we decided that Medicare rules for coverage of the polysomnography
services represented by CPT code 95810 have not been met. Therefore, we decided that the Plan does not have
to pre-approve the polysomnography services represented by CPT code 95810.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) and computed tomography (CT) services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network PET/CT services. You say that the enrollee previously received a transplant at UIC. The Plan denied your request. The Plan says the requested PET/CT scan is available in-network. The Plan says that it is not medically necessary for the enrollee to receive the requested care 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 a positron emission tomography (PET) and computed tomography (CT) services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the brain for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical information submitted does not present a rationale for a follow-up MRI.
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 requested MRI is medically reasonable or necessary. Our physician reviewer found the prior CT of the temporal bones was done without contrast. This patient has pulsatile tinnitus and severe otitis externa. For appropriate evaluation a contrast enhanced scan, MRI preferably needs to be done due to the soft tissue mass visible in the right external canal and the history of pulsatile tinnitus which may be due to a vascular abnormality. CPT 70553 MRI of the brain and Internal Auditory Canals without and with contrast would be the appropriate exam and should be approved. 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 MRI of the brain for the enrollee.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has known coronary
disease with stent placement about one year ago and no documented subsequent symptoms or findings
concerning for recurrent coronary ischemia. In this circumstance, the records do not support medical necessity
of repeat nuclear stress testing. There are no documented covered indications for the procedure 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a nuclear stress test for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on May 2, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that no tissue was removed and you
should not owe a copayment for a screening colonoscopy. The Plan denied your request. The Plan says that you
were charged the correct copayment amount because the provider billed your colonoscopy as a diagnostic
colonoscopy due to your personal history of polyps.
The Plan must follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium
enema every 2 years for people with high risk of colon cancer. An individual with a personal history of
adenomatous polyps meets the definition of "person with high risk of colon cancer" under Medicare rules.
There is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were
removed during this colonoscopy. The Plan did not submit any medical records from the ordering provider
showing what type of colonoscopy was ordered or the reason it was ordered. The procedure findings submitted
shows no polyps were removed and results were normal.
A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk
of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening
colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to
show that your screening colonoscopy benefit was exhausted on this date of service. Based on the
documentation submitted by the health plan, we find that you received a screening colonoscopy. We further
find that The Plan's contract provider incorrectly billed this colonoscopy as a diagnostic colonoscopy.
Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the
health plan cannot impose cost-sharing for the service when it is provided by in-network providers. Priority
Health must follow this rule.
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 colorectal cancer
screenings.
The Plan says you must pay a $250 copayment for a colonoscopy. Based on the Plan contract, however, you
cannot be asked to pay for colorectal cancer screenings. Therefore, we decided that the Plan has to waive the
copayment for a colonoscopy provided on May 2, 2019.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide twenty-eight (28) additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you need transportation to and from your occupational therapy and physical therapy appointments. The Plan denied your request. The Plan says that your request exceeds benefit limits.
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 twelve (12) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover above the benefit maximum for routine transportation trips. Therefore, we decided that the Plan does not have to provide twenty-eight (28) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the enrollee is too fragile to carry tanks. The Plan denied your request. The Plan says that there was no reason provided that the enrollee cannot use the equipment already provided.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a stationary oxygen concentrator and portable tanks. A stationary oxygen concentrator and portable tanks serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.