Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hearing aids to be purchased from an out of network provider.You asked the Plan to pre-approve the hearing aids. You say that you have tried other hearing aids and these are the only ones that work for you. The ones from in network provider do not have the special features and you do not like the hearing aids they offer.The Plan denied your request. The Plan says only certain types of hearing aids are covered and hearing aids must be provided by in network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from in network provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pre-approve the hearing aids to be purchased from an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee scooter provided on June 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the knee scooter. You say that you were never told that you had to go to a particular place. You were told as long as it was under $500 there should be no problem. The Plan denied your request. The Plan says this item is not covered. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 knee scooter provided on June 6, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ultrasounds (76700, 76856, 93975) provided October 16, 2019. You asked the Plan to waive the coinsurance for the ultrasounds. You say that there should be no copayment. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for Radiological Diagnostic Services. You have been asked to pay a 20% coinsurance for the ultrasounds. The ultrasounds fall within the Radiological Diagnostic 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 waive the coinsurance for ultrasounds (76700, 76856, 93975) provided October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 4, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told there would be no copayment for your post-op visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to 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 specialist office visit provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection.
You asked the Plan to pre-approve Prolia. You say that your hip and pelvis are painful. The Plan denied your request. The Plan says there is no information showing you have osteoporosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our physician reviewer found that you report a history of non-displaced peri-prosthetic acetabulum from a ground level fall. You were evaluated by an orthopedic specialist, with plan of care including a DEXA scan. The results of this exam were not available or discussed in the submitted documentation. Without this, the diagnosis of osteoporosis is not supported. Therefore, the request 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve a Prolia injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for vitrectomy face support recovery chair (E1399) provided
October 30, 2019 to November 4, 2019.
You asked the Plan to pay for the vitrectomy face support recovery chair. You say that you are appealing denial
of the claim for durable medical equipment rental of face down equipment prescribed by physician after
vitrectomy surgery. The Plan denied your request. The Plan says this item is not covered by Medicare.
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 pay for vitrectomy face support recovery chair (E1399) provided
October 30, 2019 to November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) services.
You asked the Plan to pre-approve the CTA services. You say that the enrollee has had an ABI now and the attached reports supports the need for the requested CTA. The Plan denied your request. The Plan says the records do not show the results of an ankle brachial index (ABI) study that are abnormal. The Plan says that this study could help the enrollee's doctor decide if more imaging is needed and which type of imaging would be the most helpful.
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 CTA services. Our reviewer says that the medical necessity of CTA of the lower extremities is not supported. Our physician reviewer found the enrollee has a diagnosis of peripheral vascular disease. Ankle-brachial index studies were noted to be normal bilaterally. There is no documentation of pallor, cool feet, or documented decreased pulses. Peripheral artery disease was noted as a possible diagnosis. Other differential diagnoses were not considered. 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 CTA services have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora magnetic resonance imaging (MRI) of the right knee (73721) provided on February 10, 2020.You asked the Plan to waive the copayment for the MRI of the right knee. You say that you should not be responsible for the copayment since you were not advised in advance how much the copayment would be.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $100 copayment for a Medicare-covered MRI. You have been asked to pay $100 for the MRI of the right knee. 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 magnetic resonance imaging (MRI) of the right knee (73721) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology treatment to be provided by an out-of-network provider.
You asked the Plan to pre-approve oncology treatment. You say that the enrollee had a second opinion visit with the out-of-network provider, they are familiar with the enrollee's condition, and believe that there is a good chance it could be cured. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the requested provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 oncology treatment. Our reviewer says that the enrollee does not meet the Medicare criteria for treatment with the out-of-network provider. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through its referral to in-network provider A or in-network provider B. Should tertiary level of care be needed, the Plan is offering care with in-network tertiary provider A or in-network tertiary provider B. There is not anything unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider. The Plan has shown that they have in-network providers who meet the standards of care required for treatment of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oncology treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology treatment to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom molded orthotics.You asked the Plan to pre-approvecustom molded orthotics. You say that the requested items are necessary since you are in daily pain and want to avoid surgery. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if specific criteria is 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 custom molded orthotics. Our reviewer says that the items are not medically necessary. Our physician reviewer found you have diabetes but do not have a previous amputation of the foot, or part of either foot, or a history of previous foot ulceration of either foot, or history of pre-ulcerative calluses of either foot. There is no evidence of peripheral neuropathy with evidence of callus formation of either foot, or foot deformity of either foot. The lipoma is on the ankle joint, not on the foot. There is no strong evidence of an objective vascular study or evidence poor circulation in either foot. You do not meet the Medicare criteria for custom molded orthotics.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custom molded orthotics have not been met.Therefore, we decided that the Plan does not have to pre-approve custom molded orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on September 5, 2019.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 procedure code 99152 is not supported.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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's consciousness or physiological status. 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 pay for the moderate sedation services rendered on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on January 14, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says in most cases the care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.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 the physician's services provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power operated vehicle.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere was no evaluation done by a licensed and certified professional.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not havemobility 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your personal mobility deficit impairs participation in MRADLs. There is no evidence of a power wheelchair evaluation or clear indication that you are unable to resolve your mobility deficit with a manual wheelchair. There is no trial of a power mobility device, or a detailed home assessment indicating that you would be able to safely maneuver the vehicle 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power operated vehicle
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ferumoxytol injection.
You asked the Plan to pre-approve ferumoxytol. The Plan denied your request. The Plan says the enrollee is not
anemic and does not have chronic kidney disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve ferumoxytol. Our physician reviewer
found that the enrollee is diagnosed with iron deficiency anemia, resultant from gastric bypass surgery. The
enrollee does not require dialysis or have a diagnosis of end stage renal disease. Therefore, the requested
service is determined 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 ferumoxytol have not been met. Therefore, we decided that the Plan does not
have to pre-approve a ferumoxytol injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the disposable continuous glucose monitor sensors provided on February 24, 2020.You asked the Plan to waive the coinsurance for the sensors. The Plan denied your request. The Plan says that your cost-share is correct.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 4% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 4% coinsurance for the sensors. The sensors fall within the Durable medical equipment (DME) and related 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 coinsurance for the disposable continuous glucose monitor sensors provided on February 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a mental health office visit (99214) provided on January 9, 2020.
You asked the Plan to waive the copayment for a mental health office visit. You say that you should not have a copayment since the appointment was only for monitoring/changing drugs. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $25 copayment for outpatient mental health services. You have been asked to pay $25 for a mental health office visit. 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 a mental health office visit (99214) provided on January 9, 2020.
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. You say that the enrollee needs daily labs, physician involvement, and wound monitoring. The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a chronic sacral ulcer and pulmonary emboli. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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.