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

We decided that the Plan does not have to pre-approve a transcatheter implantation of a wireless pulmonary
artery pressure sensor, CardioMEMS device (33289).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the
enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee was hospitalized in February 2021 with respiratory failure due to pulmonary overload
and possible pneumonia. The efficacy of the CardioMEMS heart failure system remains uncertain at this time.
Further clinical research is needed to determine the efficacy and safety of this device. It is not clear that the
CardioMEMS device is medically reasonable and necessary for the enrollee 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 this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve a transcatheter implantation of a wireless pulmonary artery pressure sensor, CardioMEMS
device (33289).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for echocardiography.

You asked the Plan to waive the copayment for echocardiography. You say that you disagree with how high the charges are. 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 diagnostic procedures or tests provided in an outpatient hospital facility.

You have been asked to pay a $400 copayment for echocardiography. Echocardiography falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for echocardiography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of 20 teeth (D7210).
You asked the Plan to pre-approve the extraction of 20 teeth. You say that you need these teeth extracted
because they are broken, and your gums are swollen. The Plan denied your request. The Plan says these
extractions exceed your benefit.
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, it covers only three extractions per
year. The record shows that 3 extractions were approved and the 20 additional extractions at issue were denied
in accordance with the Plan's coverage rules. Therefore, we decided that the Plan does not have to pre-approve
the extraction of 20 teeth (D7210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on September 28, 2020.
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee was in an inpatient hospital status per their claim history.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. The enrollee was inpatient during these services. Based on CMS Policy, ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission, and not separately payable. Therefore, we decided that the Plan does not have to pay for the ambulance services provided to the enrollee on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 8, 2020.
You asked the Plan to pay for the office visit. You say that authorization was not obtained but the enrollee was admitted for medical necessity. You say that you are requesting retro authorization. The Plan denied your request. The Plan says prior authorization was required but not 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a segmented appliance/sleeve for a pneumatic compression device.

You asked the Plan to pay for a pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because pneumatic compression devices to prevent deep vein thrombosis are not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules state that a PCD appliance such as E0673 is only eligible for reimbursement when the related PCD meets applicable coverage criteria. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD appliance have not been met. Specifically, the related base PCD is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, this appliance is also excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a segmented appliance/sleeve for a pneumatic compression device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance services.

You asked the Plan to waive the copay for the ambulance services. You say that the enrollee was serviced by 2 ambulances not 3. The Plan denied your request. The Plan says the claim 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copay per one-way trip for ambulance services.

The records provided show that the enrollee received ambulance services from the provider at issue. The enrollee has been asked to pay a $300 copay for the ambulance services. The services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on September 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 services provided to you by an out-of-network provider on September 28, 2019.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can safely be met at a lower level of care such as a skilled nursing facility or home with home health.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on to the enrollee by an out-of-network provider on March 31, 2020.
You asked the Plan to pay for the services. 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 had network providers available who could have provided 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 services provided on to the enrollee by an out-of-network provider on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune device and transducer arrays for the enrollee.

You asked the Plan to pre-approve these items. You say that the device is FDA approved and the health outcomes are as good if not better than the usual treatments. The Plan denied your request. The Plan says that this is not covered by Medicare for the member's condition.

The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any indications other than newly diagnosed glioblastoma multiforme will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The file indicates that these items are not being requested for the treatment of newly diagnosed glioblastoma multiforme. Therefore, we decided that the Plan does not have to pre-approve an Optune device and transducer arrays for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 22, 2020 to September 25, 2020.
You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from September 22, 2020 to September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis, adult
(D1110) and bitewings, and four radiographic images (D0274).

You asked the Plan to pay for the periodic oral evaluation, prophylaxis and bitewing x-rays. You say that you
disagree with the denial The Plan denied your request. The Plan says the services were provided by an out-of-network
provider and therefore are not covered.

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 Plan covers the periodic
oral evaluation, prophylaxis, and bitewing x-rays when the services are rendered by a contracted provider.

We looked at the Plan's list of network providers, the file, and Medicare rules. Based on this information, we
decided that the Plan's rules for coverage of the periodic oral evaluation, prophylaxis and Bitewing x-rays have
not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation
(D0120), prophylaxis, adult (D1110) and bitewings, and four radiographic images (D0274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the routine eye exam you had on October 30, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $35 copayment for each routine eye exam. Review of the file shows that you had a routine eye exam on October 30, 2020. You have been asked to pay a $35 copayment for the exam. The exam falls within the vision 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 the routine eye exam you had on October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient mental health admission.
You asked the Plan to pre-approve acute inpatient mental health admission. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not
medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 acute inpatient mental health admission.
Our reviewer says that the documentation does not support that the requested services are medically reasonable
or necessary. Our physician reviewer found it does not appear medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as the enrollee did
not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual
hallucinations. The enrollee did not appear to require inpatient mental health treatment as the enrollee was not a
danger to himself or others and was cooperative and compliant. It does not appear that active treatment is
taking place. It does not appear that the services were reasonably expected to improve the enrollee's condition
or for the purpose of diagnosis. Therefore, the enrollee does not meet criteria for the requested 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 acute inpatient mental health admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve acute inpatient mental health admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on September 8, 2020.
You asked the Plan to pay for a knee brace. You say that this should be covered. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter.The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the
treating practitioner. A review of the file does not show that the telehealth visit in which the items at issue were ordered was a substitute for an in-person encounter. The enrollee states that these items were provided following an unsolicited phone call in which he did not speak to a physician. The submitted medical records do not show that the ordering physician is the enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833, L2397) provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin.
You asked the Plan to pre-approve Xeomin. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Xeomin.
Benefits for Xeomin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 16, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG and physician services provided on November 13,
2020, by an OON provider.
You asked the Plan to pay for an ECG and physician services. You say that you would like this claim
reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that there are in-network providers available for these 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an ECG and physician services provided on
November 13, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy.
You asked the Plan to pre-approve tumor treatment field therapy. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet the
requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The documentation confirms the enrollee was diagnosed with an
aggressive brain tumor in January 2018. The documentation shows the tumor has continued to progress despite
treatment. Tumor treatment field therapy is not reasonable and necessary for the treatment of recurrent disease.
Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy have
not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy.