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

We decided that the Plan does not have to waive the deductible charge for the lab services you received on March 9, 2020.
You asked the Plan to waive the deductible charge. You say that you have never had to pay for anything for your wellness visit. The Plan denied your request. The Plan says you are responsible for the charges.
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 $0 copayment for an annual wellness visit. The annual wellness visit does not include lab tests. Review of the file shows that you were provided lab services on March 9, 2020. The services fall within the outpatient diagnostic services benefit category. The plan contract clearly states that lab services are not included in the annual wellness visit. 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 deductible charge for the lab services you received on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism. You say that the enrollee needs a seat lift chair
because of a lumbar condition. The Plan denied your request. The Plan says documentation does not show the
enrollee has severe arthritis of the hip or knee, muscular dystrophy, or other neuromuscular diseases.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We looked at the file and Medicare rules. The medical record does not show the enrollee has severe arthritis of
the hip or knee or have a severe neuromuscular disease. The record does not show the seat lift chair is part of
treatment and prescribed to improve, or stop deterioration of, the enrollee's condition. Based on this
information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.
Therefore, we decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve skilled nursing services. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available for 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 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 skilled nursing services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Spacer Implantation.
You asked the Plan to pre-approve Interlaminar/Interspinous Process Stabilization/Distraction Device (22869)
and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). You say that you
have continuous low back pain and need this device. The Plan denied your request. The Plan says there is no
reasonable expectation that the use of the experimental/investigational procedure would be any better than
other procedures you have had.
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 Interlaminar/Interspinous Process
Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process
Stabilization/Distraction Device (22870). Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is
experimental at this time. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and
Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not been met.
Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Spacer Implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP Cleaning Machine. 
 
You asked the Plan to pre-approve a CPAP Cleaning Machine. You say that keeping your CPAP clean and sanitized is medically necessary. The Plan denied your request. The Plan says this is not a covered accessory for your CPAP. 
 
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. Routine cleaning is not covered. Therefore, we decided that the Plan does not have to pre-approve a CPAP Cleaning Machine.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Charcot-Marie-Tooth genetic testing provided on November 21, 2019. You asked the Plan to pay for genetic test. You say that the enrollee's treating provider ordered this test because the results will guide appropriate medical management. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test was not medically necessary and is not covered by Medicare. 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. 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 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 specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for Charcot-Marie-Tooth genetic testing provided on November 21, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says the testing is not being used to manage or treat a specific medical problem or diagnosis. 
 
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 testing at issue in this appeal is being requested for screening purposes. There were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from September 4, 2019. You asked the Plan to waive the copayment for the emergency room visit. You say that you would like the Plan to pay for this claim. 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 $65 copayment for emergency services in an emergency room. The enrollee has been asked to pay a $65 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 emergency room visit provided from September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). You asked the Plan to pre-approve the orthosis. You say that this is an orthotic device, not a prosthetic device. It is meant for patients with arm weakness, not for missing limbs. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 24, 2020. You asked the Plan to waive the copayment for a colonoscopy. You say that if you had known what the charges would be ahead of time you would not have received the procedure. 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 $350 copayment for surgery services provided in an ambulatory surgical center. The medical records show that you had polyps removed on February 24, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the glycosylated hemoglobin testing rendered on December 16, 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 must follow Medicare rules. The rules say that glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. We looked at the file and Medicare rules. The file shows that the testing was performed for diagnoses of hypertension and dorsopathy, which are not diagnoses for which the testing is covered by Medicare. Therefore, we decided that the Plan does not have to pay for the glycosylated hemoglobin testing rendered on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 3, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. 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 physician services provided on October 3, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of bilateral knee osteoarthritis. She has received viscosupplementation therapy with hyaluronic acid in the past. Medicare approved compendia recommend initial treatment for knee osteoarthritis should include non-pharmacologic interventions as first line therapy. Furthermore, compendia do not support the use of Hyaluronan injections stating there is a lack of evidence demonstrating a benefit from its use. There is reported conflicting data to its usefulness. There is no documentation that the enrollee has tried and failed recent corticosteroid injections of the knee. The Orthovisc is 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 Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power mobility device repairs.You asked the Plan to pre-approve power mobility device repairs. You say that you need your power mobility device repaired so you are not stuck on the couch. The Plan denied your request. The Plan says to receive repairs to your power mobility device you must first qualify for a power mobility device. 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. The file does not shoe you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve power mobility device repairs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 6, 2020. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physician custom profile. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
The file shows that the enrollee received presumptive and definitive drug testing. We find that the testing is not supported in the medical record. The records do not show that the ordering physician is treating the enrollee for a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 16, 2020. You asked the Plan to pay for the office visit. You say that the medical records support the code is payable separately. The Plan denied your request. The Plan says the service is not supported as separate and significant from the debridement. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that CPT Code 99213 was billed with modifier 25. The records provided do not show the office visit was a significant, and separately identifiable service from the provided debridement. 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 office visit provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on February 17, 2020. You asked the Plan to pay for the periodic oral evaluation. You say that you spoke with the Plan and were told that preventive services should not apply to your yearly maximum. The Plan denied your request. The Plan says your benefit period maximum has been reached. 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 Plan offers a $1,000 annual dental benefit maximum. The contract says that this is the maximum amount the Plan will pay for covered dental services. The record shows that you met the annual maximum benefit on February 12, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services provided on October 11, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for cardiology services. You say that you say that you were told that everything was covered. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 cardiology services provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 25, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you feel like preventative services should be
covered regardless. The Plan denied your request. The Plan says these services could have been provided innetwork.
The Plan says that no prior authorization was obtained.
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 physician services provided on October 25, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve specialist services. You say that you would like to see this provider because he used natural remedies. The Plan denied your request. The Plan says there are in-network providers available. 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 specialist services to be provided by an out of network (OON) provider.