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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377, E2321).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no medical need to control the power options through the joystick.
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 accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found thee documentation does not reveal that you require other types of proportional input devices
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional
input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating
actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an
attendant control. Your strength and function in the right upper extremity support that you can control any
power options through their own individual switches. The E2321 exceeds your medical need and is not
medically necessary. The documentation indicates that you can operate the power wheelchair with a standard
joystick therefore the hand control remote joystick 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 the accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, E2321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a covered benefit.
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 for a pneumatic compression device (E0676).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not request for this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment without transportation
(A0998) provided on December 9, 2020.
You asked the Plan to pay for ambulance services without transportation. You say that your family insisted on
calling an ambulance, but you did not end up needing to go to the hospital. You did not realize you would be
billed for these services and they would be denied by your insurance. The Plan denied your request. The Plan
says ambulance services are a transportation benefit, and without transportation there is no payable service.
Because you did not receive transportation, this service cannot be covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 9, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without
transportation (A0998) provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays (D0220 x 2) provided on January 16,
2021.
You asked the Plan to pay for the dental services. You say that you feel that these services were denied in error.
You say that this service is specifically listed on page 4-86 of the 2021 Evidence of Coverage. The Plan denied
your request. The Plan says periapical x-rays are not listed as a covered routine dental service.
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. The record shows that you were not enrolled in the optional supplemental dental benefit which would provide coverage for this service. Therefore, we decided that the Plan does not have to pay for the periapical x-rays (D0220 x 2) provided on January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a high frequency chest wall oscillation device (HFCWOD) provided to the enrollee from November 18, 2020 to January 18, 2021.
You asked the Plan to pay for a HFCWOD. You say that this should be reconsidered. The Plan denied your request. The Plan says the records do not show any of the covered diagnoses, including no evidence of bronchiectasis on CT.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
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 a HFCWOD. Our reviewer says that the device at issue in this case is not medically reasonable or necessary. Our physician reviewer found there is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. There is insufficient evidence that this device is beneficial in the treatment of asthma or COPD. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pay for a high frequency chest wall oscillation device (HFCWOD) provided to the enrollee from November 18, 2020 to January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network benefit level.
You asked the Plan to pre-approve the referral. You say that the requested provider has a dedicated department that specializes in mitral valve problems. The Plan denied your request. The Plan says the services can be done 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 services at the in-network benefit level. You are allowed to see this provider; however, your share of the costs may be higher. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network benefit level.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (code S9502) provided from June
26, 2020, to July 2, 2020.
You asked the Plan to pay for the home infusion therapy. You say that code S9502 is included in your contract
with the Plan, and should be reprocessed. The Plan denied your request. The Plan says the denial of payment
for these services is correct, because the billed code is not valid for Medicare purposes and is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9502 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to
pay for the home infusion therapy (code S9502) provided from June 26, 2020, to July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your condition has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected that you would improve in a reasonable period of time as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant with treatment and are having no side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 14, 2020.
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says we have insufficient documentation to corroborate the services so we cannot confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for physical therapy provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tetanus shot provided to the enrollee on August 10, 2020.
You asked the Plan to pay for preventative immunizations under Medicare Part B. You say that this claim should be paid. The Plan denied your request. The Plan says this claim should be submitted to the enrollee's Medicare Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative immunizations under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to preventative immunizations under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a Tetanus shot provided to the enrollee on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon for hernia repair.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says no medical need is shown for why this cannot be received 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 a referral to an out-of-network general surgeon for hernia repair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the F1CDx testing described by current procedural terminology (CPT) code 0037U provided on July 7, 2020.
You asked the Plan to pay for CPT code 0037U. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for CPT code 0037U by a contract provider. The file does not show that the plan provided notice that CPT code 0037U would not be covered. Under Medicare rules, this means CPT code 0037U is considered approved by the plan. Furthermore, per the American Medical Association (AMA), which Medicare follows, the correct CPT code to bill F1CDx testing is 0037U. Therefore, we decided that the Plan has to pay for the F1CDx testing described by current procedural terminology (CPT) code 0037U provided on July 7, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional epidural steroid injections (62323 x 2).

You asked the Plan to pre-approve additional epidural steroid injections. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered benefit under Medicare.

The Plan must follow Medicare rules. Medicare rules say that there is no role for "series of three" ESIs.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional epidural steroid injections (62323 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatments
provided from December 16, 2020, through January 11, 2021.

You asked the Plan to waive the copayment for chiropractic manipulative treatments. You say that you were
assured that you would not owe copayments for the visits. You say that you are not happy about the large bill.
The Plan denied your request. The Plan says the copayments 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 for each Medicare-covered office visit for chiropractic services.

You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. The total amount
you owe is $160 ($20/treatment x 8 treatments = $160). Chiropractic manipulative treatments fall within the
"Chiropractic 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 chiropractic
manipulative treatments provided from December 16, 2020, through January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 18, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you were not aware you would be charged a $100 copayment. You say you were not told at the time of the scan that there would be a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 diagnostic radiology (CT, MRI, PET scan, etc.).
You have been asked to pay a $100 copayment for the CT scan. The CT scan 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 CT scan provided on January 18, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can have care at 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 in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Your medical
conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from November 5, 2020, to November 16, 2020.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that the enrollee should not be billed because they were taken off their medication. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment per day, days 1 to 4.
The enrollee has been asked to pay a $395 copayment for each day, days 1 to 4, for the inpatient hospital admission. The inpatient hospital admission falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from November 5, 2020, to November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of this injection is the absence of tenderness and negative provocative testing results has not been demonstrated in the peer-reviewed literature.

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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no physical exam findings that support the diagnosis of sacroilitis. There is no imaging that supports this diagnosis. Therefore, the request is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.