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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 13, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound should be processed under a diagnostic test or as an x-ray at a doctor's office. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $100 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $100 copayment for the ultrasound.
You have been asked to pay a $52.26 copayment for the ultrasound. The ultrasound 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 the ultrasound provided on January 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services.
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 that from a nursing perspective, the enrollee had stable vital signs. She had a history of covid-19 infection in April 2020 and she retested negative for covid-19 in May. She was treated for a cough. Her lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee did not receive or require any skilled therapy. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast ultrasound (76641) provided on December 3, 2019.
You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete. We asked our coder 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 breast ultrasound. Our reviewer says that CPT code 76641 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not support Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete being performed bilaterally on December 3, 2019, therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a breast ultrasound (76641) provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (CPT 99205).
You asked the Plan to pre-approve the services. You say that this is needed after a recent fall. The Plan denied your request. The Plan says Medicare only covers these services for manual manipulation of the spine to treat subluxation.
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 pre-approve chiropractic services (CPT 99205).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit, the x-ray, and the wrist brace provided on February 4, 2020.You asked the Plan to waive the copayments for the specialist office visit, the x-ray, and the wrist brace. You say that you cannot afford this bill. You say you would not have gone to this doctor if you knew it would cost this much.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each in-network specialist visit for Medicare-covered services, a $50 copayment for x-rays, and 20% coinsurance for all other in-network prosthetic devices and supplies for each Medicare-covered item. You have been asked to pay a total of $69.00 for the specialist office visit, the x-ray, and the wrist brace. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The wrist brace falls within the "Prosthetic devices and related supplies" benefit category. See chart below. 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 copayments forthe specialist office visit, the x-ray, and the wrist brace provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on December 9, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.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 physician order and proof of 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 Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on December 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one further home health skilled nursing visit, for a total of five.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says four visits are approved and one further is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 submitted records show that you have an unstable gait and complex regional pain syndrome. You have been receiving home health and physical therapy services. Home health nursing has evaluated you and provided education regarding your conditions and treatments. Four visits have been approved by the Plan. The records do not show that one further visit is needed to effectively provide treatment, care, and/or services in order to improve your condition or to prevent deterioration. One further visit is not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve one further home health skilled nursing visit, for a total of five.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve these services. You say that you need the scooter to get around. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a power scooter is covered when specific criteria are met. 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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a mobility limitation that significantly impairs your ability to complete mobility-related activities of daily living (MRADLs) in the home.
The documentation states that the mobility limitation cannot be sufficiently and safely resolved with the use of a cane or walker due to weakness in your arms. However, the documentation does not show an objective trial of the power scooter has been performed that indicates you can safely operate the requested device. The request therefore does not meet the Medicare criteria for coverage and is not medically necessary 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 power scooter.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 pain related to osteoarthritis of the left knee, confirmed on x-rays, and has failed conservative treatment. The records do not show that she has tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drugs would be less effective or contraindicated; therefore, Gelsyn-3 is not medically necessary 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 Gelsyn-3.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care. The Plan says that the enrollee's needed therapy can be provided in an alternate level of care.
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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management, skin care and management/care of volume status, and daily therapy can be provided at a SNF. The enrollee is mostly minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS HF System (C2624, 33289).You asked the Plan to pre-approvea CardioMEMS HF System. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a CardioMEMS HF System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMSdevice has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF System have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS HF System (C2624, 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a power operated vehicle. You say that you need a scooter you can transport in your car and get to appointments with. The Plan denied your request. The Plan says your evaluation states your power wheelchair still meets your needs and is the most appropriate PMD for you.
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 you have a power wheelchair. Your power wheelchair serves the same purpose as a power operated vehicle. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Your home assessment shows your power wheelchair meets your in home needs. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath tub wall rail, grab bar (E0241).
You asked the Plan to pre-approve a grab bar. You say that you need the safety rails because you are legally blind, suffer from imbalance and want to avoid future falls that may harm your health The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath tub wall rail, grab bar (E0241).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lymph node biopsy (38525) provided on December 18,
2019.
You asked the Plan to pay for the lymph node biopsy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the billed service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 38525 is biopsy or excision of lymph node(s); open, deep
axillary node(s) .
We asked our coder 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 lymph node biopsy. Our reviewer says that CPT code
38525 does not meet criteria for billing or reimbursement consideration. Our reviewer found the biopsy or
excision of lymph node(s); open, deep axillary node was not documented in the operative report.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the lymph node biopsy have not been met. Therefore, we decided that the Plan
does not have to pay for the lymph node biopsy (38525) provided on December 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan has to pay for an emergency department visit (99284) provided on September 1,
2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration as
this claim was denied as a duplicate in error. The Plan denied your request. The Plan says that this claim was
denied as it is a duplicate of a previously processed claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The record does not include evidence that the Plan paid for any visits. Both
claims that have been included in the documentation have been denied as duplicates and there is no explanation
as to why the initial claim has been denied as a duplicate. There is insufficient information to substantiate the
Plan's denial as the record does not demonstrate that these should be denied as duplicates. Therefore, we
decided that the Plan has to pay for an emergency department visit (99284) provided on September 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 18, 2019.
You asked the Plan to pay for drug test. You say that you are appealing. The Plan denied your request. The
Plan says the denial of payment for this service is correct, because the documentation submitted does not
include a valid physician order, lab requisition, or medical records stating exactly which tests were to be
performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for recurrent glioblastoma.
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy will be denied as not reasonable and necessary for the treatment of recurrent glioblastoma. 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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of recurrent glioblastoma. Coverage criteria is therefore not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.