Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit or the depression screening provided on October 17, 2019.You asked the Plan to waive thecopayment for the office visit and the depression screening. You say that this was an annual physical and you should be able to discuss your concerns with your provider and it should be covered in full. 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each office visit to any PCP provider and a $45 copayment for each Medicare-covered individual or group therapy visit. You have been asked to pay a $20 copayment for the office visit and an $8.54 copayment, which is less than the standard copayment amount, for the depression screening. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The depression screening falls within the "Outpatient mental health care" benefit category. The record shows diagnostic codes for personal history of other venous thrombosis and embolism and an encounter for depression screening in addition to the annual physical exam.
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 office visit or the depression screening provided on October 17, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe emergency room visit provided on October 15, 2019.You asked the Plan to reduce the copayment forthe emergency room visit. You say that you should only be charged a $45 copayment for an urgent care visit. 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). Your contract with the Plan clearly says that you must pay a $90 copayment for each hospital emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were seen in the emergency room.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 reduce the copayment forthe emergency room visit provided on October 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76775) provided on October 23, 2019.
You asked the Plan to pay for an ultrasound. You say that this should be reprocessed. The Plan denied your request. The Plan says sufficient records were not submitted to support this code.
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 76775 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited. 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 an ultrasound. Our reviewer says that CPT 76775 is not supported in the medical records. Our physician reviewer found there is no evidence that a retroperitoneal ultrasound was performed on the date of service in question. 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 ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76775) provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a creatinine lab test to be provided by an out of network (OON) provider prior to advanced PET imaging.
You asked the Plan to pre-approve the OON creatinine testing. You say that this testing is necessary and should be allowed. The Plan denied your request. The Plan says this testing does not require performance by the tertiary level provider.
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. This is a standard lab test which can be provided by any network lab and the results can be forwarded to the tertiary provider for review. 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 creatinine lab test to be provided by an out of network (OON) provider prior to advanced PET imaging.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the cervical spine for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there was an MRI in the same area from December 2019.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is symptomatic and surgical planning is mentioned. CT of the cervical spine was done 9/16/19 and there has been no documentation as to the necessity of repeating that examination. There is no history of interim trauma or significant change in symptoms to provide a valid indication for another CT of the cervical spine. If such a repeat is necessary for operative planning due to planned technique necessary to guide intra-operative approach that need is not articulated in the records submitted. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the cervical spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incision and insertion of a cranial nerve neurostimulator (64568 and 466T).
You asked the Plan to pre-approve the incision and insertion of a cranial nerve neurostimulator. You say that you have met all clinical criteria for this procedure and the LCD does not address the implantation of the Inspire System. The Plan denied your request. The Plan says the request for the hypoglossal nerve implant is not medically necessary as there is not literature to support the effectiveness of the device at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the incision and insertion of a cranial nerve neurostimulator have not been met. Specifically, per Local Coverage Article: Billing and Coding: Services That Are Not Reasonable and Necessary (A56967), the implantation of a cranial nerve neurostimulator (0466T) is not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve an incision and insertion of a cranial nerve neurostimulator (64568 and 466T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 11, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 11, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from July 17, 2019 through July 21, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibilityfor the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on July 17, 2019 and discharged on July 21, 2019. You were asked to pay a $125 copayment per day from July 17, 2019 through July 19, 2019, days 1-3 of your inpatient stay. There were no copayment charges from July 18, 2019, day 4 of your inpatient hospital care until your day of discharge July 21, 2019. Per your contract there is a $125 copayment per day required for days 1-3. This means that you have been askedto 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 forinpatient hospital care from July 17, 2019 through July 21, 2019 provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on September 17, 2019 and October 28, 2019.You asked the Plan to waive the copayment forthe MRI's. You say that you are on a leave of absence and on social security. You say that the copayment should be lowered to $50 for each MRI.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for each Medicare-covered advanced radiology service.You have been asked to pay a $175 copayment for each MRI. The total amount you owe is $350 ($175/MRI x 2 MRI's = $350). The MRI's fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe MRI provided on September 17, 2019 and October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.You asked the Plan to pre-approve an oxygen concentrator. You say that you need an oxygen concentrator.The Plan denied your request. The Plan says your O2 saturation does not meet clinical guidelines.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia for the enrollee.
You asked the Plan to pre-approve Cimzia. You say that this is medically necessary. The Plan denied your request. The Plan says that there is not enough support for Cimzia for use in the treatment of iridocyclitis.
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 Cimzia. Our reviewer says that Cimzia is not medically reasonable and necessary for the enrollee in this case. Office records indicate that the patient has uveitis (inflammation of the uvea), but that Cimzia has been ordered to treat iridocyclitis (inflammation of the iris and ciliary body). Neither of these conditions is noted to be an FDA approved condition for the use of Cimzia. Ocular problems have been reported as possible side effects of Cimzia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Cimzia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cimzia have not been met. Therefore, we decided that the Plan does not have to pre-approve Cimzia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the CPAP supplies provided on October 23, 2019.You asked the Plan to pay for the CPAP supplies. You say that the Plan should pay thisclaim.The Plan denied your request. The Plan says that the supplier did not request prior authorization.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approvedby the plan unless notice is provided that the services will not be covered. The plan  follows these rules.You were referred for the CPAP supplies to a contract provider. The file does not show that the plan provided notice that the CPAP supplies would not be covered. Under Medicare rules, this means the CPAP supplies is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe CPAP supplies provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2392) for tooth # 18 provided on September 23, 2019.You asked the Plan to pay for the dental service. You say that you had this tooth filled before but the filling fell out. You say that you asked the provider's office how much it would cost. You say that you were advised the provider would bill your insurance and let you know. You also say that you cannot afford to pay this bill.The Plan denied your request. The Plan says fillings are not s covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, fillings are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe filling (D2392) for tooth # 18 provided on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.

You asked the Plan to pre-approve the power wheelchair and accessories. You say that you questioned the home evaluation, but did not refuse it, and no one called you back. The Plan denied your request. The Plan says a home evaluation has not been completed and therefore the requested power wheelchair and accessories cannot be approved.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the beneficiary's home does not provide adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. 

The file shows that there is no evidence of a home evaluation performed. 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 a Group 3 power wheelchair and accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit and physical therapy provided  on October 16, 2019 to October 17, 2019.You asked the Plan to waive the copayment for an emergency room visit and physical therapy. You say that you would like these copayments to be waived because you were an inpatient.The Plan denied your request. The Plan says the correct copayments have been applied.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 $90 copayment for emergency care and a $15 copayment for outpatient rehabilitation services. The enrollee has been asked to pay a $90 copayment for an emergency room visit and a $15 copayment for physical therapy. The total amount you are being asked to pay is $105 ($90 + $15 = $105). Evidence was provided to show that observation services were provided overnight. Observation services are considered outpatient. An emergency room visit falls within the emergency care benefit category and physical therapy falls within the outpatient rehabilitation services 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 an emergency room visit and physical therapy provided on October 16, 2019 to October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) sleeve (L2397) ankle-foot orthosis (L1971) lumbar-sacral orthosis (L0650) provided by September 28, 2019.
You asked the Plan to pay for the orthoses. You say that review the attached documents and process the claim accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) sleeve (L2397) ankle-foot orthosis (L1971) lumbar-sacral orthosis (L0650) provided by September 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on available records, you do not meet criteria for coverage of SNF. The records do not support that you need daily physical therapy (PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. You are ambulating household distances and require little assistance with mobility and transfers. While you may benefit from continuing PT and OT, the records do not support the need for daily therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.