Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar (CPT code L0174) provided to the enrollee on August 31, 2020.
You asked the Plan to pay for the cervical collar. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 cervical collar have not been met. A review of the medical records provided show there is no documentation or confirmation of delivery proving the enrollee received the DME. There is a form indicating "Delivery Ticket" but there is no enrollee signature or date provided. There is no indication of the method of delivery. In addition, there is no exam in the enrollee's medical history, prior to the DME being ordered by the provider on the DME order, which would show a prior patient/provider relationship. The order was signed by the provider on June 9, 2020. There is no mention of the request or need for the DME until the records dated June 23, 2020, which is AFTER the date the order was signed.
Therefore, we decided that the Plan does not have to pay for the cervical collar (CPT code L0174) provided to the enrollee on August 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy.
You asked the Plan to pre-approve speech therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 speech therapy. 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 the enrollee has had prior therapy of 12 outpatient visits. The documentation does not support that the unique skills of a professional therapist are required to safely and effectively provide treatment or that the services can be safely and effectively performed only by a therapist. The enrollee has been instructed in a home exercise program. 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 speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve speech therapy.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for cardiology services.

You asked the Plan to waive the copayments for the cardiology services. You say that you did not see the cardiologist on these dates of service. The Plan denied your request. The Plan says that these copayments were charged correctly.

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 regarding the cardiology services. Specifically, you alleged that you received no cardiology services on these dates. The Plan has failed to provide any medical records showing that these services occurred. In fact, the Plan indicated in the file submitted to us that they didn't even request records from this provider. Because of this failure, we find that the Plan did not meet its burden of showing that these copayments were charged appropriately. Therefore, we decided that the Plan has to waive the copayments for cardiology services.

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 a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is needed to help get around without
assistance. The Plan denied your request. The Plan says there is no indication of a mobility limitation that
significantly impairs the ability to participate in one or more mobility activities of daily living in the home.
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 scooter. Our reviewer says that the
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation
does not support that you have a personal mobility deficit that impairs participation in MRADLs. The
documentation does not reveal that your mobility deficit is unable to be helped by a manual wheelchair or
walker. The documentation does not support that this device could be used safely in the home. There is no
evidence that this scooter will significantly improve your ability to participate in MRADLs in the home.
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 scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection.

You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the increase in charges. 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 20% coinsurance for Medicare Part B prescription drugs.

You received a Medicare Part B drug injection. The allowed amount is $1,188.18 and 20% of that is $237.64.

You have been asked to pay the total coinsurance amount of $237.64 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip arthroplasty (THA).
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 services are not urgently needed.
The Plan must follow Medicare rules. Medicare rules say that THA 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 are being
treated for left hip osteoarthritis. You have groin pain with weight-bearing activities and complaints of low
back pain radiating to the buttock area. You can walk less than one block and are using a cane for ambulation.
The exam notes mild tenderness and your left hip range of motion is limited. There is no documentation of trial
and failure of recent, reasonable, and comprehensive conservative care measures. The services are therefore not
reasonable or 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 a total hip arthroplasty (THA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on November 20, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you cannot afford the charges and require the eye injections. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on November 20, 2020. The total allowed amount is $3,712.96 and 20% of that is $742.59. You have been asked to pay the total coinsurance amount of $742.59 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on November 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 3, 2019, to August 31, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the authorized level of care should remain RVB for the entire stay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The file shows that a correct claim was requested. At this time, a correct claim has not been received. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 3, 2019, to August 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit for COVID testing provided by an out-of-network
provider on November 4, 2020.
You asked the Plan to pay for the office visit for COVID testing. You say that you had to get the test done for
the surgery center. You say that you should not be responsible for the bill. The Plan denied your request. The
Plan says that you must receive care from a network provider.
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may not impose any
prior authorization or other utilization management requirements with respect to COVID-19 testing and testingrelated
services.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit for COVID testing have been met. Therefore, we decided that the Plan has to pay
for the office visit for COVID testing provided by an out-of-network provider on November 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on September 14, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that this copayment is way too high for the brief time you spent in the doctor's office. The Plan denied your request. The Plan says the correct copayment has been applied.
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 outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology services. benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Platelet Rich Plasma injection (0232T).

You asked the Plan to pay for the Platelet Rich Plasma injection. You say that the injections were medically necessary and should be covered. The Plan denied your request. The Plan says this service is not covered.

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 Platelet Rich Plasma injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Platelet Rich Plasma injections remain experimental. More research is needed to show safety and efficacy of joint injections for orthopedic problems.

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 Platelet Rich Plasma injection have not been met. Therefore, we decided that the Plan does not have to pay for a Platelet Rich Plasma injection (0232T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology.

You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 diagnostic radiology.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement.

You asked the Plan to pay for the full mouth debridement. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth debridement.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screen testing (81404, 81406, 81439, 81479).

You asked the Plan to pay for hereditary cardiovascular screen testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular screen testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screen testing (81404, 81406, 81439, 81479).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Esbriet 267mg tablet medication.

You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under your contractual policy.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Esbriet 267mg tablet medication.

Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two further chiropractic treatments.

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 two visits are approved and two further are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are maintenance therapy. Our physician reviewer found the enrollee has undergone chiropractic treatment and was originally authorized for 13 treatments. The submitted chart notes reveal findings of taut and tender fibers, range of motion notations, with no arcs of motion given, the same assessment of good, the same three times per week plan and the same or similar treatment rendered. There is no evidence that clinical improvement has occurred or that further clinical improvement can reasonably be expected from continuous ongoing care. The requested chiropractic treatment is maintenance therapy.

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 two further chiropractic treatments.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during Arthroscopy.

You asked the Plan to pay for the assistant surgeon services during Arthroscopy. 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 supported by the documentation.

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 29824 is Arthroscopy, shoulder, surgical; distal Clavicectomy including distal articular surface (Mumford procedure).

We find that CPT code 29824 is not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of a surgical arthroscopic distal Clavicectomy, including distal articular surface (Mumford procedure); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the assistant surgeon services during arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during Arthroscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9379).

You asked the Plan to pay for home infusion therapy. You say that this was provided according to the doctor's orders. The Plan denied your request. The Plan says this was not billed with a valid code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code S9379 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9379).