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

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the routine transportation services. You say that you would like reconsideration as you believe this is a covered benefit. The Plan denied your request. The Plan says as of January 1, 2020, you are no longer eligible for non-emergent routine transportation benefits.
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 one-way trip to the home for continued acute care after discharge from an emergency room and any additional trips to a physician related to the continued acute home care. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of the routine transportation services. have not been met. You will not be returning from the ER and are requesting to schedule non-emergency transportation which is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve routine transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary for continuing pain. The Plan denied your request. The Plan says this is medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found a motorized scooter is not medically necessary per the Medicare National Coverage Determinations Manual, Section 280.3(B). The documentation indicates that you have a personal mobility deficit but the documentation is not clear that this deficit impairs participation with MRADLs in the home. The scooter assessment indicates that you can operate a lightweight manual wheelchair and recommended that you continue using his 4 wheeled walker. The documentation does not clearly indicate whether this scooter would be safe to use in your home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast with image (76641) provided on September 18, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you are appealing your $50 ultrasound copay noting you shouldn't have to pay this because the ultrasound was done due to dense breast tissue. The Plan denied your request. The Plan says outpatient diagnostic tests have a $50 copayment for each standard x-ray and ultrasound. The Plan also says that when services other than preventive are performed, the cost-share (copayment/coinsurance) associated with the other service will apply.
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 $50 copayment for outpatient diagnostic tests. You have been asked to pay a $50 copayment for an ultrasound. This service falls within the outpatient diagnostic tests benefit category. The records shows that billing codes 77063 and 77067 on the same date of service were preventive services which have no cost sharing. Billing code 76641 is for the ultrasound which is not preventative and the reason why the copayment was applied. 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 an ultrasound of the breast with image (76641) provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
You asked the Plan to pre-approve the dental services. You say that you need the dentures as soon as possible and that you are losing a lot of weight due to not having dentures. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous passive motion exercise device for use other than knee (CPT Code E0936).
You asked the Plan to pre-approve the DME. You say that your provider asked for a stretching machine because you have a shoulder problem. The Plan denied your request. The Plan says this durable medical equipment device for passive joint motion is not covered for any use other than after knee joint replacement surgery.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. This device is not a Medicare covered benefit for any use other than after knee joint replacement surgery and must start within two (2) days following surgery. Therefore, we decided that the Plan does not have to pre-approve continuous passive motion exercise device for use other than knee (CPT Code E0936).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the infrared therapy services you received from May 25, 2019 to June 19, 2019, from an out-of-network provider.You asked the Plan to reimburse you for the services provided. The Plan denied your request. The Plan says you were reimbursed based on your plan 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). Your contract with the Plan clearly says that you must pay 35% for each out-of-network physician service. The file shows that you were reimbursed the Medicare-allowed amount for each service, minus your out-of-network copay. The services fall within the physician 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 further reimburse you for the infrared therapy services you received from May 25, 2019 to June 19, 2019, from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202), application of a cast (29075), and cast supplies (Q4010, Q4050) provided on June 27, 2019 by the out of network provider.
You asked the Plan to pay for an office visit, application of a cast and cast supplies. You say that you would like the claim reviewed for payment now that the financial liability waiver has been resubmitted. The Plan denied your request. The Plan says the physician is a non-network provider who does not work with the member's health plan, and the member was referred by a facility, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 an office visit (99202), application of a cast (29075), and cast supplies (Q4010, Q4050) provided on June 27, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve urology consultation. You say that you are experiencing pain and cannot wait for an evaluation. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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 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. 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 the medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for therapeutic radiology services received from June 18, 2019 to June 30, 2019.You asked the Plan to waive the coinsurance for the services. You say that you cannot afford this.The Plan denied your request. The Plan says the coinsurance was applied correctly in this case.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 radiation therapy. You have been asked to pay 20% coinsurance ($868.26) for the services. The services fall within the radiation therapy 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 therapeutic radiology services received from June 18, 2019 to June 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) (CPT Code D5213) and complete denture - mandibular (CPT Code D5120).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) (CPT Code D5213) and complete denture - mandibular (CPT Code D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPM exercise device for use on knee only (CPT Code E0935).
You asked the Plan to pre-approve the CPM device. You say that you feel this should be covered due to being medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPM device have not been met. Coverage is limited to 21 days from the date of surgery. You had the 21 days allowed by Medicare approved, and the remaining days on the request are appropriately denied. Furthermore, studies have not supported the medical necessity or beneficial nature of continuous passive motion device beyond the initial 3-week post-operative period. Therefore, we decided that the Plan does not have to pre-approve CPM exercise device for use on knee only (CPT Code E0935).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora collagen dressing (A6021) provided on August 9, 2019.
You asked the Plan to pay fora collagen dressing. You say that this should be covered.The Plan denied your request. The Plan says payment for this item is included in the PPS facility payment.The Plan must follow Medicare rules. Medicare rules say that other than the exceptions listed above, items and services provided during an SNF stay are included in the PPS payment and cannot be billed separately.We looked at the file and Medicare rules. The item in question is not listed as an item that can be billed separately from the PPS. Based on this information, we decided that Medicare rules for coverage of a collagen dressing have not been met.Therefore, we decided that the Plan does not have to pay fora collagen dressing (A6021) provided on August 9, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the additional coinsurance for a computed tomography scan (a CT Scan) (72131) and an arthrocentesis, aspiration and/or injection, major joint or bursa (20610) provided by the facility on August 30, 2019.
You asked the Plan to waive the additional coinsurance for a CT Scan and a Bursa procedure. You say that your copay for a CT Scan is $60 and not a coinsurance of $60.02. The Plan denied your request. The Plan says outpatient diagnostic tests have a $60 copayment per visit for hyperbaric oxygen therapy; sleep studies; CT Scans, MRAs, MRIs, and PET Scans. The Plan also says that outpatient surgery services have a $250 copayment.
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 $60 copayment for outpatient diagnostic tests and a $250 copayment for outpatient surgery services. You have been asked to pay a $60 copayment for a CT Scan and a $250 copayment for an arthrocentesis, aspiration and/or injection, major joint or bursa. These services fall within the outpatient diagnostic tests and outpatient surgery services benefit category. Your bill does show a coinsurance of $60.02. That is the portion due for the treatment room used in your procedure which is separate from the copayment for the CT Scan and included with the surgery payment ($60 + $250 = $310). 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 additional coinsurance for a computed tomography scan (a CT Scan) (72131) provided by the facility on August 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that the member's needs can be met with home care or services in an office or clinic.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronics upgrades for a power wheelchair.
You asked the Plan to pre-approve electronic upgrades. You say that the enrollee needs the electronic upgrades
on the power wheelchair. The Plan denied your request. The Plan says coverage cannot be provided for
equipment used in a SNF.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the power wheelchair electronic upgrades are being requested for use in a SNF or hospital.
Therefore, we decided that the Plan does not have to pre-approve electronics upgrades for a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a TTE is covered when specific criteria are met.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 records show that the enrollee has a remote essentially normal echocardiogram, no cardiac symptoms, no cardiac physical exam abnormalities and no electrocardiographic abnormalities. There is no documented covered indication for repeat echocardiography and current guidelines do not consider repeat echocardiography appropriate in this setting.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 a transthoracic echocardiogram (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2018.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
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 lumbar-sacral orthosis (L0650) provided to the enrollee on October 9, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one beam CT capture and interpretation with limited field of view -less than one whole jaw (CPT Code D0364) and sales tax (CPT Code D9985), for the enrollee.You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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 pre-approve one beam CT capture and interpretation with limited field of view -less than one whole jaw (CPT Code D0364) and sales tax (CPT Code D9985), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for tertiary care.You asked the Plan to pre-approve these services. You say that you need to be evaluated at a higher level of care.The Plan denied your request. The Plan says the tertiary level of care is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show that you have a history of vertigo and imbalance. You were seen by an ear, nose, and throat (ENT) specialist in September of 2019. You were advised to undergo further testing but have not completed this testing. The conditions that cause vertigo are well described in ENT literature and dizziness is a common chief complaint for general ENT specialists. Your care can be handled by a non-tertiary ENT. The tertiary level of care 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a referral for tertiary care.