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

We decided that the Plan does not have to pre-approvethe white cane.You asked the Plan to pre-approvethe white cane. You say that you need the cane because you are blind and the cane you have is broken.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. A white cane for use by a blind person is more an identifying and self-help device rather than an item which makes a meaningful contribution in the treatment of an illness or injury.Therefore, we decided that the Plan does not have to pre-approvethe white cane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing care. You say that you would like this claim reprocessed and approved for payment. You say that these services were provided in a long term care facility. The Plan denied your request. The Plan says no prior authorization was obtained. The plan says that the member's primary care physician did not refer these services.
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 skilled nursing care provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an L4-L5 laminectomy (63047).
You asked the Plan to pre-approve the spinal surgery. You say that the services are reasonable and necessary.
The Plan denied your request. The Plan says there were no abormal findings on physical exam so the services
are not reasonable and necessary under Medicare guidelines.
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 spinal surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no clear correlation between physical exam and imagining study. In addition,
there is no severe stenosis on MRI, nor is there evidence of a recent MRI done.
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 spinal surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve an L4-L5 laminectomy (63047).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical trays rendered on December 10, 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 procedure code A4550 is not separately payable.The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The provider submitted a claim for procedure code A4550. This code has a status indicator of B and does not have separate payment.Therefore, we decided that the Plan does not have to pay forthe surgical trays rendered on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on February 20,
2020 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this service was medically necessary.
The Plan denied your request. The Plan says this service was not authorized.
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 the nursing facility care (99308) provided on
February 20, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan has to waive the copayment foran ER visit provided from November 12, 2019 to November 13, 2019.You asked the Plan to waive the copayment foran ER visit. You say that the claims were processed correctly and you are being charged the correct amount.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide medical records which are necessary to determine whether you were admitted inpatient followingan ER visit.Therefore, we decided that the Plan has to waive the copayment foran ER visit provided from November 12, 2019 to November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
You asked the Plan to pre-approve a transthoracic echocardiogram (93306). You say that the requested
transthoracic echocardiogram is medically necessary. The Plan denied your request. The Plan says the
requested transthoracic echocardiogram 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 a transthoracic echocardiogram
(93306). Our reviewer says that the requested transthoracic echocardiogram is not medically necessary. Our
physician reviewer found medical records from May 28, 2019 and June 21, 2019 were reviewed. The records
indicate that the enrollee has a history of mild aortic valve stenosis and congestive heart failure.
Echocardiogram done June 6, 2019 was notable for a systolic ejection fraction of 60%, no diastolic
dysfunction, mild aortic stenosis with a mean gradient of 8, and a peak gradient of 14. There was no
documentation submitted regarding a recent change in clinical status. Based on a review of the available
documentation, a repeat transthoracic echocardiogram 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 a transthoracic echocardiogram (93306) have not been met. Therefore, we
decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from October 23, 2019 to October 27, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you are appealing the services for the entire amount. You should only be charged the emergency room copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment for each day for days 1 to 4 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. The enrollee has been asked to pay a $395 copayment for each day of the inpatient hospital stay. ($395 x 4 = $1,580). The inpatient hospital stay falls within the "Inpatient Hospital Care" benefit category. The record shows you were billedfor an inpatient hospital stay.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 foran inpatient hospital stay provided from October 23, 2019 to October 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a physical therapy evaluation (97163) provided on August 28, 2019.
You asked the Plan to pay for the physical therapy evaluation. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the services of a physical therapy assistant cannot be provided incidental to a physician/appropriately licensed other practitioner as they are not specifically licensed as physical therapists.
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 97163 is physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the physical therapy evaluation. Our reviewer says that CPT code 97163 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not support that a qualified health care professional performed this evaluation. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a physical therapy evaluation (97163) provided on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 13, 2020. You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the test billed. The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on December 3,
2019.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes .
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the therapeutic activities. Our reviewer says that CPT code
97530 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include documentation of activities or modalities for each timed therapy procedure
performed on December 3,2019, therefore CPT 97530 59 cannot be verified as an independent procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan
does not have to pay for therapeutic activities (97530) provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on January 8,
2020.
You asked the Plan to pay for a chiropractic office visit. You say that you only received spinal manipulation.
The Plan denied your request. The Plan says this processed correctly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for a chiropractic office visit (99202) provided on January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Halaven for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the use of this drug requires use as a single agent therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the he enrollee has a diagnosis of metastatic breast cancer. Medical records support the enrollee is receiving Tecentriq with disease progression. The enrollee previously received Keytruda. Plan of care is the addition of Erubilin. Review of the compendia notes requirements for previous treatment with an anthracycline and a taxane. Compendia also notes Halaven was trialed as monotherapy. Documentation supports the planned use as a dual therapy regimen. Medical necessity is not supported.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Halaven for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment foran inpatient hospital stay provided from September 28, 2019 to October 2, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you should not be responsible because you had a previous inpatient hospital stay within 60 days.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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from September 28, 2019 to October 2,2019. Therefore, you are responsible to pay the $295 copayment for days 1-3 (September 28, 2019 to September 30, 2019). $295 (copayment) x 3 (inpatient days) = $885. You have been asked to pay the total copayment amount of $885 for an inpatient hospitalstay. An inpatient hospital stay falls within the inpatient hospital care 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from September 28, 2019 to October 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for Emergency Room services provided January 9, 2020.
You asked the Plan to pay an additional amount for the Emergency Room services. You say that you are being
billed the balance of the cost by the provider, in addition to the $90 copayment. The Plan denied your request.
The Plan says the correct cost-sharing has been applied and they have paid the facility the Original Medicare
payable 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 $90
copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room
services fall within the Emergency Care 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. The plan has already paid the Medicare allowed amount. Therefore, we
decided that the Plan does not have to pay an additional amount for Emergency Room services provided
January 9, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab work provided by an out-of-network lab on October 18, 2019.
You asked the Plan to pay for lab work. You say that you are an independent lab who relies on the referring physician to obtained prior authorization. The Plan denied your request. The Plan says that no prior authorization was obtained.
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 lab work by a primary care physician. The provider is a contract provider. The file does not show that the plan provided notice that lab work would not be covered. Under Medicare rules, this means lab work is considered approved by the plan. Therefore, we decided that the Plan has to pay for lab work provided by an out-of-network lab on October 18, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) provided March 6, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing because you were in great pain in 2 teeth due to the silver fillings were leaking and had to be fixed with new fillings. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 resin-based composite - two surfaces, posterior (D2392) provided March 6, 2020.
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 medically necessary. The Plan denied your request. The Plan says the device cannot be brought into the house due to a lack of ramp.
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 indicate that your personal mobility deficit impairs participation in MRADLs. There is no evidence that you are unable to maneuver or use a manual wheelchair safely. The documentation states that this will elevate your blood pressure, but there is no evidence of a significant evaluation of blood pressure with the manual wheelchair. The documentation indicates that there is no ramp in the home to use the scooter. 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.