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

We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment.

You asked the Plan to waive the coinsurance for portable oxygen equipment. You say that you are disputing the bill. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered items.

You have been asked to pay $17.84, which is 20% of the allowed amount for the portable oxygen equipment. The allowed amount is $89.21 (20% x $89.21 = $17.84). Portable oxygen equipment falls within the "Durable medical equipment (DME) and related 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 coinsurance for portable oxygen equipment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140 x 2), the unspecified preventive service (D1999), the periapical x-ray (D0220), and the limited oral evaluation (D0140).

You asked the Plan to pay for the dental services. You say that your tooth started to hurt. You say that you were not able to get an appointment right away. You say that the dentist advised both teeth were rotten. You say that you decided to have the 1 tooth pulled that was causing you pain. You say that the dentist advised you should have the other tooth. You also say that you should only be responsible for the first extraction (half of the $513) since you made the decision to have that one pulled. The Plan denied your request. The Plan says the services you received are not listed as covered services.

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 the extraction (D7140 x 2), the unspecified preventive service (D1999), the periapical x-ray (D0220), and the limited oral evaluation (D0140).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Superion Vertiflex interspinous device.

You asked the Plan to pay for the device. The Plan denied your request. The Plan says this 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 pay for the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the
device.

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 device have not been met. Therefore, we decided that the Plan does not have
to pay for the Superion Vertiflex interspinous device
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for non-emergent transport.

You asked the Plan to pay for this transport. You say that this transport was medically necessary. The Plan denied your request. The Plan says the enrollee did not have prior authorization for non-emergent transport.

Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says prior authorization is required for non-emergent transportation. The enrollee did not have prior authorization for this transport. The Plan rules were not followed in obtaining this service. Therefore, we decided that the Plan does not have to pay for non-emergent transport provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72148).

You asked the Plan to pre-approve the MRI of the spine. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.

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 the MRI of the spine. Our reviewer says that the MRI of the spine is not medically necessary. Our physician reviewer found the documentation does not include a history or an examination or any other objective evidence to establish the medical reasonableness or necessity of the requested service. 

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 MRI of the spine have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up portable x-ray equipment services coded R0070 and the transportation of portable x-ray equipment and personnel services coded Q0092.

You asked the Plan to pay for the set-up portable x-ray equipment services and the transportation of portable x-ray equipment and personnel services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes R0070 and Q0092 are not supported in the medical record. Specifically, these services were billed with place of service 31 (skilled nursing facility). There is no inpatient skilled nursing facility claim on file to support this place of service billed. Based on this information, we decided that Medicare rules for coverage of the set-up portable x-ray equipment services and the transportation of portable x-ray equipment and personnel services have not been met. Therefore, we decided that the Plan does not have to pay for the set-up portable x-ray equipment services coded R0070 and the transportation of portable x-ray equipment and personnel services coded Q0092.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the state taxes applied to an eyewear purchases on July 16, 
2020, and July 29, 2020. 
 
You asked the Plan to pay for state taxes. You say that you would like to be reimbursed for the taxes applied to 
vision services. The Plan denied your request. The Plan says Medicare does not cover vision services and the 
Plan does not reimburse state or retail taxes on services and purchases. 
 
Medicare does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 
eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
The Plan contract does not include reimbursement for state or retail taxes applied to vision purchases.  
Therefore, we decided that the Plan does not have to pay for the state taxes applied to an eyewear purchases on 
July 16, 2020, and July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

The patient was admitted for lumbar spinal surgery. Her medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 

Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Coflex device (CPT code 22867). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are not enough studies to show Coflex is safe and effective to treat back pain. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device remains experimental. More research is needed to show safety and efficacy. 
There is no instability clearly documented on motion x-rays. Hardware not needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a Coflex device (CPT code 22867).
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 the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says the transportation benefit has been exhausted for the year. 
 
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 24 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. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee was admitted for a cerebellar stroke, facial cellulitis and Clostridium difficile colitis. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology office consultation and follow-up visits for the 
enrollee, to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that this enrollee was previously seen at this provider 
for other services, and they want to go there. The Plan denied your request. The Plan says the enrollee has in-
network providers who can provide this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
urology office consultation and follow-up visits for the enrollee, to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis center for the 
enrollee. 
 
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 dialysis center for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgery services. 
 
You asked the Plan to pre-approve vascular surgery. You say that your doctor wants to go in and correct a 
procedure which was previously done. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because you are currently enrolled in a hospice program and therefore the Plan is 
not responsible for coverage of these services at this time. 
 
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.  
 
You are currently enrolled in hospice with a planned termination date of April 30, 2021. Therefore, the Plan is 
not responsible for coverage of the requested surgery services at this time. Therefore, we decided that the Plan 
does not have to pre-approve vascular surgery services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the COVID-19 test (87635) provided October 18, 2020. 
 
You asked the Plan to pay for the COVID-19 test. You say that you had to pay this fee because you were 
coming home from taking care of a sick cousin in Arizona. You flew back to New Jersey to your daughter and 
had to be in work Monday morning. That's why you needed to do the COVID 19 test. The Plan denied your 
request. The Plan says Per the temporary COVID-19 policy, tests will not be covered for members who need a 
COVID-19 test to travel or to return to work for general workplace safety.  
 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The plan covers coronavirus related testing when medically necessary and 
prescribed by a provider, including but not limited to radiology and other lab tests regardless of the place of 
service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for 
the COVID-19 test (87635) provided October 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay for a reverse total shoulder arthroplasty for 
the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says care could be provided without an inpatient stay after the surgical 
procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the approved shoulder surgery does not require an inpatient stay. The documentation 
notes the request for the right total shoulder arthroplasty is supported. However, this procedure is indicated as 
an outpatient procedure (if without specifically detailed significant risk factors.)  Detailed documentation is not 
evident regarding significant co-morbidities and/or past medical history (that would significantly increase the 
risk of peri- and/or post-operative complications) that would warrant presumptive approval of inpatient 
hospitalization. Therefore, the request for inpatient stay for right shoulder surgery 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient stay for a reverse total shoulder arthroplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve intradialytic parenteral nutrition (IDPN). You say that the requested IDPN is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested intradialytic parenteral nutrition (IDPN). 
 
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 intradialytic parenteral nutrition 
(IDPN). Our reviewer says that the enrollee does not meet criteria for the requested intradialytic parenteral 
nutrition (IDPN). Our physician reviewer found the enrollee has end-stage renal disease (ESRD) and is 
currently receiving hemodialysis. She is noted to have a low albumin level despite R.D. counseling, increased 
oral protein and supplements. She has been diagnosed with hypoalbuminemia and severe protein malnutrition. 
IDPN was requested. The records do not show that the enrollee has a GI dysfunction that would prevent them 
from taking in nutritious liquid food prepared by the enrollee and their caretakers. Parenteral nutrition is not 
supported for this enrollee, and this request for such will be considered 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 intradialytic parenteral nutrition (IDPN) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).