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

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on March 28, 2021.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams on this date. The Plan denied your request. The Plan says this is not separately payable without a modifier.

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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on March 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin sealants, protectants, moisturizers, ointments (A6250) provided on December 17, 2020.

You asked the Plan to pay for the skin sealants, protectants, moisturizers, ointments. You say that you would like the denial code changed to non-covered charges, per Medicare guidelines. The Plan denied your request.

The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skin sealants, protectants, moisturizers, ointments (A6250) provided on December 17, 2020.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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. Our physician reviewer found there are no complex nursing or rehabilitation needs. You do require physical and occupation therapy, but there is no documented need for an intensive rehabilitation program.
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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are necessary for you to get to your medical appointments. The Plan denied your request. The Plan says our benefit only allows 48 trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, your Plan only allows 48 one-way trips for routine transportation. Any trip over the 48 allowed is not covered.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 3, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 physician services provided to the enrollee on November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve the massage therapy. You say that you feel massage therapy should be a covered service. You say that your old insurance policy covered massage therapy and it helped you to stay healthy because you were able to exercise every day. The Plan denied your request. The Plan says massage therapy is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the hydration therapy rendered on May 12, 2020.
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 that the services are not covered.
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 states that the services were rendered in the state of New Jersey and that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to support that the services were rendered in New Jersey. The claim dispute form lists a National Provider Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to pay for the hydration therapy rendered on May 12, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88341) provided January 25, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the number supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 88341 are not supported in the medical record. The medical record only supports 1 unit of CPT code 88341. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88341) provided January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical record shows you have stabilized medically, and you are ready for discharge from the hospital. The records do not show that you require daily skilled nursing or daily skilled therapy services. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. Your physical function is at or near baseline. You may require custodial care given the injury to the shoulder, but that is not covered by Medicare. Admission to a skilled nursing facility for inpatient skilled rehab services 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a power wheelchair.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are 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 a referral to an out-of-network provider for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the wrist orthosis, the out-of-network urgent care visit, and the x-ray you received on September 3, 2020.
You asked the Plan to waive the cost sharing for the wrist orthosis, the out-of-network urgent care visit, and the x-ray. You say that you feel as if you were not diagnosed correctly, so you shouldn't have to pay this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing 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 20% coinsurance for durable medical equipment, a $40 copayment for out-of-network urgent care visits, and a $14 copayment for x-rays.
You have been asked to pay 20% coinsurance for the wrist orthosis, a $40 copayment for the out-of-network urgent care visit, and a $14 copayment for the x-ray. This means that you have been asked to pay the correct amount based on your contract with the Plan. There is no provision for a waiver of these amounts if you are dissatisfied with the care you received. 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 cost sharing for the wrist orthosis, the out-of-network urgent care visit, and the x-ray you received on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on March 2, 2021.
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 procedure codes S1015 and S8301 are not payable.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. 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 for the supplies rendered on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan and the bone scan you had on November 20, 2020.
You asked the Plan to waive the copayments for the CT scan and the bone scan. You say that these scans were done at the same time and should be considered as one procedure. The Plan denied your request. The Plan says you had two separate and distinct tests during a single encounter. The Plan says that you were appropriately charged two separate copayments.
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 diagnostic radiology services. You have been asked to pay a $200 copayment for the CT scan and a $200 copayment for the bone scan. the
Each of these tests falls within the diagnostic radiology services benefit category. These services are two different tests with different billing codes, so two separate copayments apply. 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 copayments for the computed tomography (CT) scan and the bone scan you had on November 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch -Genicular, left (62640).
You asked the Plan to pre-approve destruction by neurolytic agent. You say that the service is medically necessary. The Plan denied your request. The Plan says genicular nerve radiofrequency ablation is still being studied in clinical trials for efficacy in the treatment of knee pain due to osteoarthritis or in the setting of replacing or significantly deferring total knee arthroplasty.
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 destruction by neurolytic agent. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because it is
the subject of on-going clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent have not been met. Specifically, this procedure is considered experimental, and therefore, is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch -Genicular, left (62640).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that admission to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the enrollee is currently receiving care at an acute care hospital, which can provide ongoing acute care services. An LTACH would not provide a clinical advantage and the enrollee's current medical condition is not stable for transfer. Once the enrollee's condition is more clinically stable, then an appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on December 22, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you have a family history of breast cancer so this test is medically necessary. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $160 copayment for radiological diagnostic services.
You have been asked to pay a $160 copayment for the breast ultrasound. The breast ultrasound falls within the radiological diagnostic 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 the breast ultrasound you had on December 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the lumbar spine (72158).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that an MRI is needed to help determine your next step. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the lumbar spine. Our reviewer says that the requested service is not medically necessary at this time. Our physician reviewer found that you had a vertebroplasty and are having back pain. There is no documentation indicating that you are taking any pain medications or anti-inflammatory medications like Ibuprofen, or participating in any exercise program, modification of activity that worsens your pain, or physical therapy, or that the pain is causing significant interference with daily function. There were no documented abnormal physical exam findings consistent with lumbar neuropathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the lumbar spine (72158).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyewear.

You asked the Plan to pre-approve the eyewear. You say that you have eyeglasses, but your vision has worsened, and you do not have a job so you cannot pay out of pocket for new eyeglasses. The Plan denied your request. The Plan says you are not eligible for your vision benefit at this time.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.

We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on 
April 8, 2020 and you are not eligible for coverage of eyewear again until April 1, 2022. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pre-approve eyewear
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the nuclear bone scan you had on February 3, 2021.
You asked the Plan to waive the deductible for the nuclear bone scan. You say that you do not understand why these claims were denied. The Plan denied your request. The Plan says you had not yet met your $500 annual deductible at the time of these services, so you are responsible for the full amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 annual deductible for medical services that must be satisfied before the Plan will pay towards your claims. In this case, the Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 annual deductible. This cost sharing is a contractual obligation that had not been met at the time the nuclear bone scan was received on February 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the nuclear bone scan you had on February 3, 2021.