Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 4 additional physical therapy visits. You asked the Plan to pay for 4 additional physical therapy visits. You say that you are finally experiencing some progress. You say that you have prescriptions from more than one doctor stating you need the therapy. The Plan denied your request. The Plan says the additional visits are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 4 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you previously had extensive therapy and was trained in a home exercise program. Our physician reviewer also found that the unique skills of a professional therapist are not required to safely and effectively provide continued treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pay for 4 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676). You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis. The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on
February 26, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says this claim was submitted without
an appropriate first listed or principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99285 is not supported in the record. Specifically, per the ICD-10 Guidelines, diagnosis
code M10.431 has a "code first" note. This indicates that the diagnosis for the underlying condition should be
sequenced first. Based on this information, we decided that Medicare rules for coverage of the emergency
department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency
department visit (99285) provided on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with
concurrently acquired computed tomography (CT) scan of a limited area (78814).
You asked the Plan to pre-approve a PET CT scan of a limited area. 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 PET 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 a PET CT scan of a limited area. Our
reviewer says that the services are not medically necessary. Our physician reviewer found the chest x-ray report
does not describe a cavitary lesion in the right upper lobe. While it is true PET is often indicated for the
evaluation of pulmonary nodules to indicate the likelihood of malignancy the report in this case does not
provide an indication for PET. In addition, the notes indicate the enrollee is due for an annual low dose lung
CT to evaluate for malignancy in this enrollee with significant smoking history. There is no reason the low
dose lung CT should not be performed prior to a PET scan. If the CT shows a suspicious cavitary lesion rather
than a finding related to a rib a PET scan may be indicated at that point. Absent the performance of the annual
low dose lung CT the indications for PET/CT are not met.
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 PET CT scan of a limited area have not been met. Therefore, we decided that
the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired
computed tomography (CT) scan of a limited area (78814).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME and related supplies provided on January 10, 2020.
You asked the Plan to waive the deductible for DME and related supplies. You say that it would be a hardship to find another provider. 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. Your contract with the Plan says that there is a $1,500 deductible for out-of-network DME and related supplies. You received DME and related supplies on January 10, 2020 from an out-of-network provided. The record shows that you had paid $0 toward the $1,500 out-of-network deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $178.59. The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for out-of-network DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME and related supplies were received on January 10, 2020. Therefore, we decided that the Plan does not have to waive the deductible for DME and related supplies provided on January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the breast biopsy provided on March 5, 2020. You asked the Plan to reduce the copayment for the breast biopsy. You say that you were told this was a diagnostic procedure and would only be billed a $20 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each Medicare-covered outpatient surgery at an in-network outpatient hospital. You have been asked to pay a $325 copayment for the breast biopsy. The breast biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the breast biopsy 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 reduce the copayment for the breast biopsy provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care stay
provided from February 11, 2020 to February 13, 2020.
We asked the Plan to waive the copayment for the inpatient mental health care stay. You say that you should
not be responsible for this copayment 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 a $295
copayment per day, days 1 to 7 at an in-network inpatient hospital.
You have been asked to pay a $590 copayment for the inpatient mental health care stay. ($295 x 2 days =
$590). The inpatient mental health care stay falls within the "Inpatient mental health 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 the inpatient mental health care stay provided from February
11, 2020 to February 13, 2020.
Your complaint about fraud is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 7, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was a wellness visit and you should not be charged a copayment. 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 $20 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness visit on November 7, 2019. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 20,
2020.
You asked the Plan to waive the copayment for emergency care. You say that you were very sick with Covid-
19 and needed a chest X-ray but no provider would see you so you had to go to the emergency room where
staff was very dismissive. 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 $90
copayment for emergency care.
The medical records show that you received emergency care on March 20, 2020. Therefore, you are
responsible to pay the $90 copayment.
You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on
March 20, 2020.
We note your complaint about how the emergency department staff were dismissive. Your complaint is a
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about
these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on May 11, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 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 lab work provided on May 11, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for transcranial Doppler study of the intracranial arteries provided on February 6, 2020. You asked the Plan to waive the copayments for transcranial Doppler study of the intracranial arteries. You say that you should only owe $20 not $150 per each line item. 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 $150 copayment for each radiological diagnostic service. You received transcranial Doppler study of the intracranial arteries on February 6, 2020 for a total of 3 services. Therefore, you are responsible to pay a $150 copayment per each service. The total amount you owe is: $450. You have been asked to pay the total copayment amount of $450 for transcranial Doppler study of the intracranial arteries. Transcranial Doppler study of the intracranial arteries fall 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 copayments for transcranial Doppler study of the intracranial arteries provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre system.
You asked the Plan to pre-approve a FreeStyle Libre system. You say that the item is necessary. 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 CGM devices are covered when 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 a FreeStyle Libre system. Our reviewer
says that the item is not medically necessary. Our physician reviewer found the criteria for CGM coverage
require insulin use and adjustment in insulin dose according to blood glucose (BG) level. You are not using
insulin. Furthermore, we are not told why glucometer use is not sufficient for you in that it too provides BG
levels like libre; the libre does not have an alarm so its advantage over glucometer is only the ability to check
BG without pricking the finger and we are not told why this is needed in this case.
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 FreeStyle Libre system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a FreeStyle Libre system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve RFA. 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 follows Medicare rules. Medicare rules say that therapeutic injections are covered when 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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of prior diagnostic medial branch blocks (MBBs) or RFA at the level of C6-C7. This request would also exceed the utilization limit. Therefore, the request is considered 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for a medical alert system.
You asked the Plan to pre-approve coverage for a medical alert system. You say that coverage for a medical alert system is medically necessary. The Plan denied your request. The Plan says a medical alert system is precautionary, and it 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 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 coverage for a medical alert system.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF admission are not met.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee does not require an intensive rehabilitation therapy program provided in an IRF. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network benefit be applied to medical services provided by an out of network (OON) provider.
You asked the Plan to pre-approve the home doctor visit with an out of network provider at the in-network benefit level. You say that the records provided support the need for the care being requested. The Plan denied your request. The Plan says the services being requested are available from an in network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an in-network benefit be applied to medical services provided by an out of network (OON) provider.
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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit from and/or participate in an IRF 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.