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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 20, 2020.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism (E0627) and the lift chair (E1399) provided on January 4, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the provider is not certified for Medicare and therefore, is not a Medicare-Certified provider.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism and lift chair have not been met. Specifically, the items were purchased from a provider that is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism (E0627) and the lift chair (E1399) provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on February 24, 2020.You asked the Plan to waive the copayment for the spinal injection. You say that you went to your doctor's office inside the hospital for the injection and you do not feel the outpatient copayment should apply. You say this was an injection and not surgery. 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 $395 copayment per visit. You have been asked to pay a $395 copayment for the spinal injection. The spinal injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital. Also, the injection 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 spinal injection provided on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no medical
issues that require supervision by an inpatient rehab physician 3 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that the enrollee presented to the hospital with malaise, generalized weakness, and ataxia status post medical
management. The hospital course included optimizing cardioprotective medications. Now, the enrollee is at
minimal assist for mobility and transfers. He is at moderate assist for activities of daily living, such as
grooming and dressing. The complexity of the enrollee's nursing, medical, and rehab needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs close medical management, therapy for strengthening, and adaptive equipment training.The Plan denied your request. The Plan says the enrollee does not require 3 hours of therapy daily, or close checking by a doctor 3 times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 physician reviewer found that the enrollee is generally medically stable with a left hemiparesis from a stroke and dementia with no recent neurological or Orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently the enrollee is at a max assist to dependent level functionally. While the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on January
23, 2020.
You asked the Plan to waive the copayment for the echocardiography. You say that you were unaware of your
responsibility at the time. You say that you cannot afford to pay the invoice. The Plan denied your request. The
Plan says the copayment 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 $55
copayment for each covered diagnostic procedure or test at a network doctor's office.
You have been asked to pay a $55 copayment for the echocardiography. The echocardiography falls 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 for the echocardiography provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam services provided on January 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe eye exam services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 careand 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 forthe eye exam services provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization.
You asked the Plan to pre-approve prostatic arterial embolization. You say that the requested prostatic arterial embolization is medically necessary. The Plan denied your request. The Plan says the requested prostatic arterial embolization 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 prostatic arterial embolization. Our reviewer says that the requested prostatic arterial embolization is not medically necessary. Our physician reviewer found the enrollee is with a 10-year history of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). He could not tolerate finasteride, and doxazosin has not been effective. Request is for coverage of prostatic arterial embolization (PAE). PAE is considered experimental/investigational and as such, is not medically reasonable and necessary for the enrollee in this case. According to the most recent AUA Guidelines, "PAE is not recommended for the treatment of LUTS attributed to BPH outside the context of a clinical trial". We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostatic arterial embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided by an out-of-network provider on February 25, 2020.You asked the Plan to waive the deductible for an office visit.You say that you were told that the provider took your insurance. The Plan denied your request. The Plan says the correct deductible amount has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for physician/practitioner services/out-of-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for physician/practitioner services/out-of-network. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on February 25, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided by an out-of-network provider on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leather recliner chair.
You asked the Plan to pre-approve the recliner chair. You say that you need to keep your legs lifted. The Plan denied your request. The Plan says the chair is not primarily medical in nature.
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 leather recliner chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72156). You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says the MRI is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there is an approval code for the same study, or a similar study, that is on file in the enrollee's records that has expired. The clinical information provided for this review does not document results of the approved study, or if the approval expired without being used. Guidelines do not support additional imaging without knowing the outcome of the prior approval and, therefore, the request is not indicated 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72156).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 18, 2018 by an out of network (OON) provider. You asked the Plan to pay for these services. You say that the enrollee provided incorrect information. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 the medical services provided on December 18, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided January 28, 2020 to February 3, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital careprovided.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 paya $390 copayment per day,fordays 1-5 and a $0 copayment per day,for days 6-90for inpatient hospital care. You have been asked to pay a $1,950 copayment ($390 x 5 days) for inpatient hospital care. 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 copaymentfor the inpatient hospital care provided January 28, 2020 to February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from January 29, 2020, to February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from January 29, 2020, to February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Krystexxa injection for the enrollee.You asked the Plan to pre-approve the injection. You say that  The Plan denied your request. The Plan says the notes received from the doctor's office do not show an adequate trial and failure of, intolerance to, or contraindication to Febuxostat (Uloric).Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee with chronic gout, there was supportive evidence of having failed and not tolerated allopurinol. Consideration for a different medication is reasonable in this situation. However, the provided records did not show any evidence of having tried and failed, been intolerant to, or had a contraindication to using Uloric (febuxostat). There was no documentation of significant cardiac disease or severe kidney disease. Based on current evidence and the provided documentation, a trial of Uloric would not necessarily be less effective or likely to have side effects for this patient compared to the requested Krystexxa injection. 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Krystexxa injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous blood glucose monitor.
You asked the Plan to pre-approve continuous blood glucose monitor. You say that the enrollee is very familiar with insulin pump technology. For over 1 year she has been buying her insulin pump supplies out of pocket but can no longer can afford to do it. The Plan denied your request. The Plan says the documentation provided by your physician does not support the need for a continuous glucose monitor.
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 continuous blood glucose monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The documentation in the case file does not support that the coverage criteria as established by LCD L33822 have been met in this case. The case file does not contain clinical documentation that the enrollee is insulin-treated with 3 or more daily injections of insulin or a Medicare-covered continuous insulin infusion (CSII) pump. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous blood glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous blood glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you did not realize the specific plan the member had. You say that you were not given all this information at the time of the visit. The Plan denied your request. The Plan says no prior authorization was obtained. The plans says that these services could have been provided 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 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 physician services provided on December 31, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (CPT D6245) and a porcelain/ceramic retainer crown (CPT D6740).
You asked the Plan to pre-approve the pontic and crown. You say that you are not happy with the time spent trying to get your bridge fixed. You say that you have problems eating. The Plan denied your request. The Plan says the services in dispute are not covered dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (CPT D6245) and a porcelain/ceramic retainer crown (CPT D6740).