Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health services to be provided by an out of network provider.

You asked the Plan to pre-approve mental health services with an out of network provider. You say that you want to see this provider to manage your mental health. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve mental health services to be provided by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that physical therapy is necessary, and your physical therapist told you that you are making tremendous improvement and would need to continue treatment for at least 6 more months. The Plan denied your request. The Plan says additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive therapy for your condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in and you are compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 10 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on
February 28, 2020.
You asked the Plan to pay for the initial hospital care 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. 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 99223 is initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor
or unit.
We find that CPT code 99223 is not supported in the medical record. Specifically, this code is considered part
of the global surgical package of minor procedure (code 52005), which was billed by the same provider on the
same date of service. Based on this information, we decided that Medicare rules for coverage of the initial
hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the
initial hospital care services coded 99223 provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services you received on November 20, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not provided.
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 records or documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services you received on November 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging,
tomographic (SPECT) (CPT code 78452) and regadenoson 0.1MG injection (CPT code J2785) provided on
January 20, 2021.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received myocardial perfusion imaging, tomographic (SPECT) and a regadenoson 0.1MG injection on January 20, 2021. You were asked to pay a $250 copayment for the diagnostic testing. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs.
The allowed amount is $237.48. The total you owe is $47.50 ($237.48 x 20% = $47.50). Your total cost share responsibility is $297.50 ($250 + $47.50 = $297.50). Your 2020 EOC states that enrollees must pay a $250
copayment for Medicare-covered diagnostic radiology services (not including X-rays) and enrollees must pay
20% of the cost for Part B covered prescription drugs. 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
myocardial perfusion imaging, tomographic (SPECT) (CPT code 78452) and regadenoson 0.1MG injection
(CPT code J2785) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on
December 10, 2020.
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request.
The Plan says there is a $40 for each Medicare-covered outpatient visit for services to diagnose and/or treat a
disease or condition of the eye.
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 $40
copayment for vision care Medicare-covered outpatient visit.
You have been asked to pay $40 copayment for the ophthalmological services. The ophthalmological services falls within the vision care Medicare-covered outpatient visit 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 ophthalmological services provided on December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive audiometry threshold
evaluation and speech recognition (CPT code 92557) provided on February 4, 2021.

You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that the provider never
acknowledged you and never bothered to come in to address your concerns. The Plan denied your request. The
Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received a diagnostic hearing exam on February 4, 2021. You were asked to
pay a $40 copayment for the exam. Your 2021 EOC states that enrollees must pay a $40 copayment for a
Medicare-covered diagnostic hearing exam. 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 comprehensive audiometry threshold evaluation and speech recognition (CPT code 92557) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial upper denture (D5820), resin-based composite-two surfaces, anterior (D2331), and the intraoral-periapical first radiographic image (D0220) provided from March 18, 2021, through March 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services provided are not payable as they were rendered by a non-participating dental provider.
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. 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, the dental services were rendered by a non-participating provider. The Plan contract says that services received from dentists who do not participate
in the network are not covered benefits. If you receive services from a dentist that does not participate
in the network, you will be responsible for the full cost of those services. Therefore, we decided that the Plan does not have to pay for the interim partial upper denture (D5820), resin-based composite-two surfaces, anterior (D2331), and the intraoral-periapical first radiographic image (D0220) provided from March 18, 2021, through March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Cystourethroscopy (52356) and Urography (74420) provided in an ambulatory surgical center on December 11, 2020.
You asked the Plan to waive the copayment for the Cystourethroscopy and Urography. You say that you would like reconsideration because the Plan sent a letter agreeing to waive all out-of-pocket costs. The Plan denied your request. The Plan says you have a $245.00 for ambulatory surgery services provided at an in-network outpatient hospital.
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 $245 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $245 copayment for the Cystourethroscopy and Urography. The Cystourethroscopy and Urography falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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. The services that were provided are not primary care, outpatient behavioral health or telehealth, and they do not qualify for the out-of-pocket waiver. Therefore, we decided that the Plan does not have to waive the copayment for the Cystourethroscopy (52356) and Urography (74420) provided in an ambulatory surgical center on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the sacroiliac joint, with image guidance (64625).

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 this service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this service is considered an experimental/investigational procedure due to the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 20, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 20, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dual battery pack and external battery charger for G3 Inogen portable oxygen concentrator.

You asked the Plan to pre-approve a dual battery pack and external battery charger. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

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 the Inogen system that is complete with an internal battery, an AC charger, and a DC charger. The documentation supports that the enrollee would be expected to plug the unit in while traveling in the care or while in the waiting room or clinic room of a facility. To add a double battery in order to not carry a charger would be considered a convenience or luxury. This means that the enrollee's current battery and chargers serve the same purpose as a dual battery pack and external battery charger. Therefore, we decided that the Plan does not have to pre-approve a dual battery pack and external battery charger for G3 Inogen portable oxygen concentrator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on February 9, 2021.
You asked the Plan to pay for the paramedic intercept services. You say that the paramedic went aboard and assisted enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove upgraded electronics for a Group 3 Power wheelchair including an expandable controller (E2377), harness (E2313), and electronic connector to 2 power options (E2311).

You asked the Plan to preapprove the upgraded electronics. You say that the claims should be covered. The Plan denied your request. The Plan says the upgraded electronic wheelchair accessories are not necessary.

The Plan must follow Medicare rules. The rules say that the upgraded electronics are used to control power tilt, recline and power elevating leg rests through the joystick. They state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to preapprove upgraded electronics for a Group 3 Power wheelchair including an expandable controller (E2377), harness (E2313), and electronic connector to 2 power options (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CxBladder) provided to the enrollee on November 6, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the denial is appropriate given the clinical scenario.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the medical literature does not support the clinical value of this specific testing to be considered medically necessary. Noninvasive urine tests are not currently recommended by guideline panels owing to insufficient clinical benefit. The information submitted with the appeal does not confirm that Medicare coverage criteria have been 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (CxBladder) provided to the enrollee on November 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on January 25, 2021.

You asked the Plan to pay for the paramedic intercept services. You say that you provided advanced life support services. The Plan denied your request. The Plan says this item is not a covered benefit.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from October 14, 2020, through November 7, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from October 14, 2020, through November 7, 2020. There was no copay for days 1-20. However, for days 21-25, there was a $160 copay each day, for a total copayment of $800. Your 2020 EOC states that enrollees must pay a $0 copayment per day for days 1- 20 of a benefit period and $160 per day for days 21 - 44 of a benefit period, and $0 per day for days 45 -100 of a benefit period. 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 SNF care provided from October 14, 2020, through November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and application of a modality services provided by a chiropractor from May 27, 2020 to September 23, 2020.
You asked the Plan to pay for the office visits and application of a modality services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits and application of a modality services provided by a chiropractor from May 27, 2020 to September 23, 2020.