Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shoulder surgery provided on December 23, 2019.You asked the Plan to waive the copayment for the shoulder surgery. You say that you did not have surgery and you already paid a $40 copayment. 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 $125 copayment for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $125 copayment for the shoulder surgery. The shoulder surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed for a closed treatment of a fracture of the upper end of the upper arm bone which is considered a surgical procedure.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 shoulder surgery provided on December 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99212 and 99213), venipuncture (36415) and pharmacy services (A9153) provided on August 12, 2019 through November 21, 2019.You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you went to this provider after being dismissed by a prior provider without resolution.The Plan denied your request. The Plan says the services you received are not covered services from a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Additionally, the internal medicine provider has opted out of Medicare and there is no evidence that the certified registered nurse anesthetists was under the supervision of a non-opted out physician.Therefore, we decided that the Plan does not have to pay for office visits (99212 and 99213), venipuncture (36415) and pharmacy services (A9153) provided on August 12, 2019 through November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from January 6, 2020 to January 13, 2020.You asked the Plan to pay for the subsequent nursing facility care.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 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 subsequent nursing facility care provided from January 6, 2020 to January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on October 28, 2019.You asked the Plan to waive the copayment for specialist services. You say that you were not aware that the provider was out-of-network.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for out-of-network specialist services.You received out-of-network specialist services on October 28, 2019. Therefore, you are responsible to pay the $70 copayment.  You have been asked to pay a $70 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on October 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT of the chest and an MRI of the head.You asked the Plan to pre-approve the CT and the MRI. You say that the requested services are medically necessary for continued surveillance.The Plan denied your request. The Plan says the clinical information provided does not describe signs or symptoms of metastatic disease involving the brain. The Plan says that routine brain imaging of asymptomatic patients is not supported for this malignancy without prior brain involvement and, therefore, the request for an MRI is not indicated at this time. The Plan say that the guidelines for coverage of the requested CT scan have not been met without identifying the state of the disease.The Plan must follow Medicare rules. Medicare rules say that MRIs and CTs 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 CT and the MRI. Our reviewer says that the requested MRI and CT scans are not medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have small cell lung cancer, for which he completed treatment in December 2016. There is no evidence that the enrollee ever had brain metastasis. There is no evidence that the enrollee is currently experiencing new or worsening symptoms. As such, surveillance imaging of the brain and every six month imaging of the chest is not medically necessary or reasonable.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 CT and the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT of the chest and an MRI of the head.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a facet joint injection provided on February 25, 2020.You asked the Plan to waive the copayment for a facet joint injection. You say that you paid your copayment and disagree with the additional charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a facet joint injection on February 25, 2020. A face joint injection is an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $243.75, which is less than the $350 copayment. You have been asked to pay the copayment amount of $243.75 for a facet joint injection. A facet joint injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora facet joint injection provided on February 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an endoscopy (43235) provided by a provider who has opted out of Medicare on October 30, 2019.You asked the Plan to pay for an endoscopy. You say that you did not have time to find an in-network doctor.The Plan denied your request. The Plan says payment cannot be made to an opt-out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for an endoscopy (43235) provided by a provider who has opted out of Medicare on October 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.You asked the Plan to pre-approve acupuncture. You say that this was recommended to treat your pain.The Plan denied your request. The Plan says this is not covered for your condition.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that you have chronic low back pain. The acupuncture at issue has been requested for neck pain and myalgia.Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the enrollee previously had ambulance services that were covered by the Plan with only a member copay. You asked the Plan to reconsider their denial.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran inpatient consultation (99251) provided on November 4, 2019.You asked the Plan to pay foran inpatient consultation. You say that this consultation was provided to discuss surgery.The Plan denied your request. The Plan says this was billed with an invalid 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.We find that CPT code 99251 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met.Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99251) provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 23, 2020.You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 23, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from December 19, 2019 to December 24, 2019.You asked the Plan to pay for home infusion therapy. You say that this should be reprocessed.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.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 code S9500 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided from December 19, 2019 to December 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an emergency room visit and x-ray provided August 26 to August 30, 2019.You asked the Plan to waive the copayments the emergency room visit and x-ray. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct copayments were 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). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care and a $75 copayment for X-rays. You have been asked to pay a $90 copayment for Emergency Care and a $57.01 copayment for X-rays.The allowable amount of $57.01 for the X-rays is less than the $75 stipulated in the contract.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 an emergency room visit and x-ray provided August 26 to August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora seat lift mechanism of a seat lift chair.You asked the Plan to pay for a seat lift mechanism. You say that with a seat lift mechanism you would be able to get up off your furniture and not rely on someone else.The Plan denied your request. The Plan says the is no medical record of severe arthritis of hip or knee, or neuromuscular disease, or that this is your physician's course of treatment.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pay fora seat lift mechanism of a seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Life Vest provided to the enrollee from September 14, 2019 through September 17, 2019.You asked the Plan to waive the coinsurance for the Life Vest. You say that the enrollee did not know about his financial obligation.The Plan denied your request. The Plan says that the enrollee has a 20% coinsurance for high cost DME supplies.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 20% coinsurance for high cost durable medical equipment. The enrollee has been asked to pay a 20% coinsurance for the Life Vest. The Life Vest falls within the high cost durable medical equipment 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 coinsurance for the Life Vest provided to the enrollee from September 14, 2019 through September 17, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve an ultraviolet multidirectional light therapy system in a 6 foot cabinet (CPT E0694).You asked the Plan to pre-approve an ultraviolet multidirectional light therapy system. You say that only the hand-foot UV machine requested will work for treating the lesions on her feet.The Plan denied your request. The Plan says that Medicare will not cover an ultraviolet cabinet if you do not have a diagnosis of psoriasis.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 ultraviolet multidirectional light therapy system. Our reviewer says that an ultraviolet multidirectional light therapy system is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a potentially lethal cancer that responds to treatment with ultraviolet radiation (UVB). The treatment needed is not currently available in a doctor's office and the enrollee is having a flare.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 ultraviolet multidirectional light therapy system have been met.The National Coverage Determination (NCD) that the Plan referenced as the basis of their decision does not explicitly exclude coverage of this device for indications other than psoriasis.Therefore, we decided that the Plan has to pre-approve an ultraviolet multidirectional light therapy system in a 6 foot cabinet (CPT E0694).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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT Scan of the abdomen and pelvis (74176).You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because you have been experiencing constant left lower quadrant pain.The Plan denied your request. The Plan says the medical notes received do not support the need for this service.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 CT Scan. Our reviewer says that the provided documentation did not show that the enrollee had lost 5% of his body weight within a twelve-month period. The notes, also, do not show that he has completed an age-appropriate cancer screening. Our physician reviewer found the requested CT scan of the abdomen and pelvis is not medically necessary or reasonable.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 CT Scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT Scan of the abdomen and pelvis (74176).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic liner and sleeve from an out of network (OON) provider.You asked the Plan to pre-approve the out of network prosthetic liner and sleeve. You say that the plan's suggested provider does not have your best interest at heart. You say that they are rude. You say that you need sleeves and liners, as they both have holes in them. You say that without them you have no livelihood, as you can't walk. You say that the requested out of network provider knows how to treat their clients.The Plan denied your request. The Plan says medically necessary care is available in-network.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 prosthetic liner and sleeve from an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cell stimulating therapy provided on August 7, 2019 through December 3, 2019.You asked the Plan to pay for the cell stimulating therapy. You say that you would like reconsideration as this service was medically necessary.The Plan denied your request. The Plan says this service was not medically necessary or the standard of care for the member's condition.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 cell stimulating therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee received electrical nerve stimulation, vasopneumatic treatment and/or nerve bed vitamin injections to treat chronic lumbar back pain. These services do not appear to have been medically necessary, reasonable, safe or effective.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 cell stimulating therapy have not been met.Therefore, we decided that the Plan does not have to pay for cell stimulating therapy provided on August 7, 2019 through December 3, 2019.