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

We decided that the Plan has to waive the copayment for the ultrasound provided on March 12, 2020.You asked the Plan to waive the copayment for the ultrasound. You say that you were informed this was covered in full as a preventive service. You say that the copayment should be $0.The Plan denied your request. The Plan says that the copayment applied correctly.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 members eligible for the abdominal aortic aneurysm preventive screening. The Plan says you must pay a $30 copayment for the ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment. The medical records show that the aortic ultra sound was ordered as a screening due to family history.Therefore, we decided that the Plan has to waive the copayment forthe ultrasound provided on March 12, 2020.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 True Metrix glucose test strips 300/75.
You asked the Plan to pre-approve True Metrix glucose test strips 300/75. You say that the items requested are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of True Metrix glucose test strips 300/75 have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test strips 300/75.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria for IRF care are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided, the enrollee does not require the intensity of
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of
care. Medicare coverage criteria are 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found according to the records provided, current clinical status required ongoing ventilation weaning and monitoring which warrants an acute care facility stay. However, there are no services required that are available at the LTACH that are not already available at the current acute care facility. There was no indication that more than 25 days of an acute care facility stay would be needed. There are no services available at the proposed LTACH that the enrollee requires that are not available and covered at the current acute care facility. Therefore, based on the provided documentation, the requested LTACH services will be considered 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on February 18, 2020.
You asked the Plan to pay for a shingles vaccine and administration. You say that you were not informed you would be charged for this vaccine. The Plan denied your request. The Plan says this vaccine is only covered under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on February 18, 2020.
Benefits for a shingles vaccine and administration 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lower left ankle and foot 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 no information or details were provided to indicate the need for this request.
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 not medically reasonable or necessary. Our physician reviewer found the notes in this case all concern the left foot and the possible Morton's Neuroma would be best investigated by MRI. One would assume the xrays series done in this case is of the left foot and was mistakenly described as right foot. The MRI cannot yet be called 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lower left ankle and foot for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy re-evaluation rendered on December 10, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97164 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 97164 and 97535. Code 97164 is a column II code with a modifier indicator of 1 when billed with column I code 97535. Code 97135 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the physical therapy re-evaluation rendered on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.
You asked the Plan to pre-approve the requested device. You say that you want to be able to get around the house. The Plan denied your request. The Plan says you are unable to maneuver a scooter safely.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 requested device. Our physician reviewer found that you were noted to have abnormal gait, weakness, and normal range of motion. There was no detailed neuromuscular exam of the upper or lower extremities on this document. The documents do not address your lack of coordination and lack of upper body strength. There is no detailed home assessment indicating that you can safely operate a PMD. Therefore, the requested scooter is not medically reasonable and 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 5, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you are disputing the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit to an in-network specialist for Medicare-covered services. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician services, including doctor's office visits" 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 office visit provided on February 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP monitoring feature provided on March 3, 2020.
You asked the Plan to pay for the monitoring feature. You say that you need the CPAP so the Plan should pay this claim. The Plan denied your request. The Plan says the payment for the monitoring feature is incorporated into the payment for the CPAP and you are not responsible for this payment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Services given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. We looked at the file and Medicare rules. The Plan has paid for the CPAP. The monitoring feature is included and was provided by a contract provider. You are not responsible for this payment. Therefore, we decided that the Plan does not have to pay for the CPAP monitoring feature provided on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient rehabilitation facility admission.The Plan must follow Medicare rules. The rules say that an 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 that your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records provided do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing level of care. Ongoing pain medication,other medication management, wound care, and daily therapycan be provided at a skilled nursing facility. A less intensive, longer duration of therapy is appropriate.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copay for the outpatient clinic visit provided on February 10, 2020.
You asked the Plan to waive the copay for the outpatient services. You say that you did not see any doctor at the hospital. The Plan denied your request. The Plan says that the copay was applied toward the processing of the claim.
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 enrollees must pay a $0 copay for outpatient hospital coverage. The Plan says you must pay a $30 copay for the outpatient services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copay for the outpatient hospital services. Therefore, we decided that the Plan has to waive the copay for the outpatient clinic visit provided on February 10, 2020.
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: 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 IRF services are medically necessary. The Plan denied your request. The Plan says your rehabilitation needs at present are not complex and do not require an interdisciplinary approach with multiple specialists to oversee your rehabilitation 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 while the patient may benefit from continuing therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Admission to an IRF is not medically necessary based on medical stability and functional status. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 70450) provided on February 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the payment for another service.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70450 is part of an edit pair with procedure code 70496. Procedure code 70496 is a column one code, and procedure code 70450 is a column two code. Procedure code 70496 has been paid for this date of service, which means that procedure code 70450 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 70450) provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts for balance.
You asked the Plan to pre-approve shoe inserts. You say that shoe inserts are necessary to relieve the pain in
your feet. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
shoe inserts may be appropriate for you, neither Medicare nor the Plan provides coverage of this item for your
condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan.You asked the Plan to pre-approve the bone scan. You say that the bone scan is needed.The Plan denied your request. The Plan says the enrollee is in a clinical trial and original Medicare would be responsible to cover the costs of the service in dispute.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve the bone scan as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approve a bone scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical examination and evaluation (92014) scanning computerized ophthalmic diagnostic imaging (92133) provided on December 5, 2019.
You asked the Plan to pay for the vision services. You say that you were not aware the provider did not accept your health plan and that prior authorization was needed. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in-network provider. We looked at the file and the Plan's rules. Vision services are covered when provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for medical examination and evaluation (92014) scanning computerized ophthalmic diagnostic imaging (92133) provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiation services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON radiation services. You say that you would like to continue receiving services from the out-of-network provider. The Plan denied your request. The Plan says these 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 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 the radiation services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 4, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration because no authorization was needed to render these services. The Plan denied your request. The Plan says the claim was not billed per Medicare guidelines for home health claims.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include a valid treatment authorization code or HCPCS code. Therefore, we decided
that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 4, 2019.