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

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical
spine (72156).
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the service is necessary. The
Plan denied your request. The Plan says there is already an approval for the same or similar study in your
records. Additional imaging cannot be approved without knowing the outcome of the prior approval.
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 an MRI of the cervical spine. Our
reviewer says that the service is not medically necessary. Our physician reviewer found the reviewed records
provided show an approval for an MRI of the cervical spine on file, effective March 10, 2020. However, there
are no results of this study, or if there are plans for the study. Further imaging cannot be approved without
knowing the outcome of the prior approval. Therefore, the requested MRI of the cervical spine 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 an MRI of the cervical spine have not been met. Therefore, we decided that the
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72156).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on January 8, 2020.
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says the enrollee must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 a duplex scan provided on January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study provided on March 4, 2018.
You asked the Plan to pay for the sleep study. 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 a sleep study provided on March 4, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided November 13, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided November 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on January 31, 2020.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you paid your specialist copayment but you do not agree with the additional copayment for the hearing exam. You say you have a $0 copayment for an annual hearing exam. 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 $45 copayment for exam to diagnose and treat hearing and balance issues. You have been asked to pay a $45 copayment for the comprehensive hearing test. The comprehensive hearing test falls within the "Hearing services" benefit category. The record shows a diagnosis of conductive and sensorineural hearing loss which makes the hearing test diagnostic in nature.
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 comprehensive hearing test provided on January 31, 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 the enrollee does not need a multidisciplinary team or visits from a physician.
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 at minimal assist with ambulating using a wheeled walker. The enrollee is stable on room air. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's INR is still not therapeutic. Her other medical comorbidities do not require intensive physician or nursing oversight only in an IRF. The enrollee may benefit from additional multiple therapies, however her functional level, which is noted to be limited due to weakness, fatigue and deconditioning do not require or indicate that this therapy must be in an IRF with an intensive level 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on July 29, 2019 and January 3, 2020.
You asked the Plan to waive the copayments for ambulance services. You say that you only owed a $25 copayment in the past. 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 $250 copayment for ambulance services provided in 2019. Your contract with the Plan also clearly says that you must pay a $275 copayment for ambulance services provided in 2020. You received ambulance services on July 29, 2019. Therefore, you are responsible to pay the $250 copayment. You received ambulance services on January 3, 2020. Therefore, you are responsible to pay the $275 copayment. The total amount you owe is: $525. You have been asked to pay the total copayment amount of $525 for ambulance services. Ambulance services fall within the ambulance 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 copayments for ambulance services provided on July 29, 2019 and January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required (D2950 x3).
You asked the Plan to pre-approve the core buildups. You say that the enrollee has a fracture on tooth #20 due to wear. You also say that tooth #'s 11 and 6 were worn out due to heavy bruxism, and a new crown is required for proper support and retention. The Plan denied your request. The Plan says Medicare does not cover this service and therefore this service is not covered by the enrollee's plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three core buildups, including any pins when required (D2950 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction (92015) provided December 10, 2019.
You asked the Plan to pay for the vision services. You say that You were referred for this appointment for a
specific problem of double vision and swelling in your left eye. Your charts will reflect that this was the 4th
doctor seen for this problem. The Plan denied your request. The Plan says the service was rendered as a part of
a medical exam for a pre-existing medical issue and is therefore not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when performed by a participating provider and performed as a
routine eye exam.
We looked at the file and the Plan's rules. eye refractions are only covered if performed by a participating
provider and performed as a routine eye exam. Based on this information, we decided that the Plan's rules for
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for
eye refraction (92015) provided December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator provided on February 12, 2019.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you were told that there was no out-of-pocket expense for the defibrillator. You say you do not agree with this amount.
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 20% coinsurance per Medicare-covered item. You have been asked to pay $579.90 which is 20% of the allowed amount for the automatic external defibrillator. The allowed amount is $2,899.50. ($2,899.50 x 20% = $579.90). The automatic external defibrillator falls 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 automatic external defibrillator provided on February 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 22, 2019.
You asked the Plan to pay for the laboratory services. 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 laboratory services provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the scaling due to inflammation (D4346).
You asked the Plan to pre-approve the scaling due to inflammation. The Plan denied your request. The Plan says scaling due to inflammation is not listed as a covered service.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the scaling due to inflammation (D4346).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on September 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 medical services provided to you by an out-of-network provider on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical face mask (A4928).
You asked the Plan to pre-approve a surgical face mask. You say that you need a facial mask to go to the store as you have tried using a scarf, but you were unable to breathe easy. The Plan denied your request. The Plan says a surgical face mask is not a covered benefit under your contractual policy.
The Plan covers all items that Medicare covers. Medicare rules state that surgical face masks are not covered because they are non-reusable, disposable items. While a surgical face mask may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a surgical face mask (A4928).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that a Group 2 power wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a Group 2 power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Group 2 power wheelchair and accessories. Our reviewer says that a Group 2 power wheelchair and accessories is not medically necessary. Our physician reviewer found in this case, the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this 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 a Group 2 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
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 the enrollee's current needs are being met in the 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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for cellulitis and osteomyelitis. The enrollee is not intubated/ventilated. The enrollee is to receive a prolonged course of antibiotics. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you can use your walker inside your house but when going out to stores you need a power mobility device. The Plan denied your request. The Plan says per your evaluation you are able to perform mobility related activities of daily living using your walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 9, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November 30, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told the ambulance ride would be covered. 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 $250 copayment for ground travel. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the ambulance ride.
You have been asked to pay a $248.46 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 copayment for the ambulance ride provided on November 30, 2019.