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

We decided that the Plan does not have to waive the copayment for an ultrasound and an X-ray provided on September 24, 2019.
You asked the Plan to waive the copayment for an ultrasound and an X-ray. You say that you do not understand the $65.74 charge. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for basic radiological services provided in an outpatient hospital. You have been asked to pay a $95 copayment for an ultrasound and an X-ray. An ultrasound and an X-ray fall 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 an ultrasound and an X-ray provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe laboratory services rendered on April 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression devices.You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression devices
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to enrollee on September 6, 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 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 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 to enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitoring sensors.
You asked the Plan to pre-approve continuous glucose monitor sensors. You say that the enrollee is non-compliant with standard glucometer testing. The Plan denied your request. The Plan says the record shows the enrollee is not on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Criteria for a CGM have not been met. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitoring sensors.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression devices.You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery or at this location.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression devices.
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 services 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. 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 enrollee is not shown to 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. 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 Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) on March 6, 2019.You asked the Plan to pay for the MRI. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers that could have provided the service.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) on March 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator.
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the enrollee has chronic low back pain radiating down to bilateral lower extremities. The Plan denied your request. The Plan says peripheral nerve stimulation is considered experimental and investigational.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve stimulator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network psychology services. You say that you have been in therapy with this provider for almost 10 years and have had a positive response for your condition. You say that you already have a big record with this out-of-network provider and that you were not going to be changing providers because it was not favorable for your condition. The Plan denied your request. The Plan says they had in-network providers who could have supplied the services which were denied.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychiatry services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on October 31, 2019.You asked the Plan to pay forthe panoramic x-ray. You say that you asked the provider twice before your appointment what your out of pocket expense, if any, would be and you never got an answer.The Plan denied your request. The Plan says this service is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.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 forthe panoramic x-ray provided on October 31, 2019.Please note, this decision is solely focused on the October 31, 2019 date of service. For any other claim inquiries, please contact your Plan.Your complaint about your issues with the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physician's services provided on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye surgery or waive the coinsurance for the phenylephrine and ketorolac ophthalmic irrigation solution provided on October 24, 2019.You asked the Plan to waive the copayment forthe eye surgery and waive the coinsurance for the phenylephrine and ketorolac ophthalmic irrigation solution. The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered outpatient hospital facility visit and a 20% coinsurance foreach Medicare-covered Part B drug. You have been asked to pay a $200 copayment for the eye surgery and a 20% coinsurance for the phenylephrine and ketorolac ophthalmic irrigation solution. The eye surgery falls within the Medicare-covered outpatient hospital facility visit benefit category and thephenylephrine and ketorolac ophthalmic irrigation solution falls within theMedicare-covered Part B drug 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 forthe eye surgery andwaive the coinsurance for the phenylephrine and ketorolac ophthalmic irrigation solution provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurosurgeon consultation for the enrollee.
You asked the Plan to pre-approve the consultation. You say that this is medically necessary. The Plan denied your request. The Plan says there are no red flags that allow the plan to deviate from the physiatrist evaluation prior to approving a neurosurgeon consultation.
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 the consultation. Our reviewer says that the requested consultation not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented in November 2019 with a 6-week history of back pain with no radicular symptoms. Lumbar range of motion was within normal limits, and neurologic exam did not evidence a focal neurologic deficit. It was noted that the enrollee had a history of arthritis, spinal stenosis, and L5/S1 disc bulging, but imaging was not provided. There was radiographic evidence of multilevel degenerative changes with osteophytes and grade 1 spondylolisthesis at L4/5. Under consideration is a request for neurosurgical consultation as an exception to Health Plan rules that require an evaluation with a Spine Center of Excellence (physiatrist) prior to neurosurgical referral. There are no clinical exam findings documented in the available medical records that would warrant urgent neurosurgical evaluation. There is no compelling rationale presented to support an exception to Health Plan requirements. Therefore, based on the available medical records, the neurosurgical consultation is not urgently needed enough to bypass the requirement to see the Spine Center of Excellence first. 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 consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurosurgeon consultation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level pain management specialist.

You asked the Plan to pre-approve these services. You say that you have seen this provider since 2001. The Plan denied your request. The Plan says the tertiary level of care 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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show that you have narrowing of the neck spine (cervical spinal stenosis). You had spine surgery in 2002 and 2003. The records do not show any indication for which care at a tertiary level facility would be medically necessary. Your care can be provided by a non-tertiary provider.

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 referral to a tertiary-level pain management specialist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on January 31, 2019.You asked the Plan to pay fordrug tests. You say that the services billed are supported by the record.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS) code. We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an officesetting, therefore the Place of Service (POS) code 81, indicating an independent laboratory setting, is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, wedecided that the Plan does not have to pay fordrug testing provided on January 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen and pelvis for the enrollee.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was assessed to have a calcified aorta, for which a CTA was ordered. In the absence of current signs or symptoms, such a test is not indicated. The documentation does not support that the requested CTA is currently medically necessary or reasonable.

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 computed tomography angiography (CTA) of the abdomen and pelvis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 1, 2019 to August 5, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other thana SNF.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 1, 2019 to August 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
August 9, 2019 to August 16, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were transferred
between hospitals and this should be covered as one continuous stay. 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 $370
copayment per day for days 1 through 5 for covered hospital care. Thereafter, you pay a $0 copayment for
additional Medicare-covered days during your hospital admission.
You have been asked to pay a $370 copayment for each day, for the first 5 days of the inpatient hospital stay.
($370 x 5 = $1,850). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The
medical record shows you were discharged from the first hospital on August 9, 2019.
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 inpatient hospital stay provided from August 9, 2019 to
August 16, 2019.