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

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 5,
2020 and billed under code 93010.
You asked the Plan to pay this claim. You say that the Plan should pay for these services. The Plan denied your
request. The Plan says that payment for this service would be included in the facility PPS payment. Payment
for this service is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for this service would have been included under the facility claim. Payment to you for this
service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay
for physician services provided to the enrollee on October 5, 2020 and billed under code 93010.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE).
You asked the Plan to pre-approve the TTE. 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 pre-approve the TTE. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee has no known history of coronary artery disease or heart failure. An echocardiogram
done in 2019 showed normal left ventricle function and mild mitral valve disease. She has had no intercurrent
cardiac events since that time and denies symptoms of dyspnea, chest pain or any other cardiac type symptoms.
She is being treated with anti-hypertensives and has no signs on exam of congestive heart failure. In the
absence of any cardiac symptoms or signs and the relatively normal echo in 2019, and no prior severe valvular
heart disease, the enrollee would not meet appropriate use criteria for repeat echocardiography at this time.
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 TTE have not been met. Therefore, we decided that the Plan does not have
to pre-approve a transthoracic echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on September 14, 2020 to October 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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. The file shows that the provider billed procedure code S9090 (vertebral axial decompression, per session). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on September 14, 2020 to October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), consultation (D9310), first 15 minutes of deep sedation/general anesthesia (D9222), and two subsequent 15 minute increment of deep sedation/general anesthesia (D9223 x2) provided on September 4, 2020, and October 16, 2020.
You asked the Plan to pay for the panoramic x-ray, consultation, and deep sedation/general anesthesia services. You say that you were advised if you paid $1,013 for these services that the rest would be covered by the insurance company. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the panoramic x-ray (D0330), consultation (D9310), first 15 minutes of deep sedation/general anesthesia (D9222), and two subsequent 15 minute increment of deep sedation/general anesthesia (D9223 x2) provided on September 4, 2020, and October 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the critical care services rendered from September 28, 2020 to October 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a clear denial reason for these services. There is no documentation or Medicare rules to support that the services are not covered. Therefore, we decided that the Plan has to pay for the critical care services rendered from September 28, 2020 to October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrocardiogram (93000) and an office visit (99205) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are providers within the network that can provide the requested services.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an electrocardiogram (93000) and an office visit (99205) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

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. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The record shows that you received a bitewing x-ray that was denied for being considered an integral part of a more comprehensive service, and benefits not being available. The EOC lists bitewing x-rays as a covered service, limited to one set per calendar year, and you must pay a 50% coinsurance when the bitewing x-ray is received out-of-network. Bitewing x-rays are not listed as an exclusion if they are provided on the same day as an endodontic therapy. You reasonably believed this service would be covered at the out-of-network benefit rate because it is listed as a covered service. Therefore, we decided that the Plan has to pay for the bitewing x-ray.
We also decided that the Plan does not have to pay for the endodontic therapy, or pay more for the intraoral x-ray, problem focused limited oral evaluation, and resin-based composite.
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, endodontic therapy is not among those covered under this benefit. The contract clearly says that you are responsible for a 50% coinsurance for intraoral x-rays and emergency diagnostic exams, and you are also responsible for a 55% coinsurance for resin-based composites that are received out-of-network. You are also responsible for the difference between the billed amount and allowed amount for services received out-of-network. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, or pay more for the intraoral x-ray, problem focused limited oral evaluation, and resin-based composite.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseus radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. 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 pre-approve the RFA. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that this is considered an experimental/investigational procedure at this time. Therefore, the request is
deemed 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 the RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve intraosseus radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on July 25, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan has insufficient documentation to corroborate the services to confirm Medicare coverage has been met.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physician's services have not been met. Therefore, we decided that the Plan does not have to pay for physician's services that you provided on July 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on February 2, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think it is fair that you are being charged for this visit because you left before being seen due to the long wait. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care.

You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit did take place, regardless of whether services were rendered or not; therefore, the correct copayment has been applied. An emergency room visit falls within the emergency care 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 an emergency room visit provided by a participating provider on February 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on
December 22, 2020.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that this was a routine
office visit, and the enrollee was told they would only owe a $25 copayment. The Plan denied your request.
The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $125 copayment for advanced imaging services provided at hospital outpatient facilities.

The enrollee received myocardial perfusion imaging at an outpatient hospital facility on December 22, 2020.
Myocardial perfusion imaging is considered advanced imaging. Therefore, the enrollee is responsible to pay
the $125 copayment.

The enrollee has been asked to pay a $125 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on December
22, 2020.
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 needed for multiple doctor appointments. The Plan denied your request. The Plan says the plan benefit limit has been exceeded.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that this equipment is medically necessary for you to walk. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
You asked the Plan to pre-approve PBRT. 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. 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 PBRT. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more
beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials,
and to not routinely offer it to patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee can remain at the current acute care hospital (ACH) until such time no
acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any
ongoing long-term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that in this case, you have a sacral decubitus that is being treated, and a below knee amputation. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. Therefore, the requested services are 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 these services are medically necessary. The Plan denied your request. The Plan says the necessary care can be provided at another skilled level and does not require acute rehab admission.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary
services can be provided in a different 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is being dispensed for self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.