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

We decided that the Plan does not have to pre-approve10 additional physical therapy visits.You asked the Plan to pre-approvethe 10 additional physical therapy visits. You say that the enrollee has progressive symptoms and is very bothered by freezing of gait. You say that, previously, physical therapy has significantly helped the enrollee with his balance and gait.The Plan denied your request. The Plan says the clinical information does not support that the requested physical therapy is 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 pre-approve the 10 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 the enrollee has already attended 18 treatments since the start of care. There is no history of recent falls and his treatments should have included instruction in a home exercise program. Given the number of treatments already provided, the enrollee appears to have reached a plateau in improvement. Physical therapy provided in excess of what is medically necessary may promote dependence on therapy provided treatments rather than a regularly performed home exercise program. A daily home exercise program would best meet this enrollee's needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 10 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional physical therapy visits.
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
October 1, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment because you were the provider told you were not supposed to have an
appointment until April. 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 $50
copayment for specialist visits.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
you were seen for kidney stones.
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 October 1, 2019.
Your complaint about the long wait time 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on August 1, 2019.
You asked the Plan to waive the copayment for the MRI. You submitted your bill for review. You say that you were informed you owe nothing on the bill. 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 $100 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $100 copayment for the MRI. The MRI 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 MRI provided on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have had trouble with your feetfor several years and your doctor feels orthotics may help.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on March 4, 2019.You asked the Plan to pay forthe 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on March 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay formanipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) (23700) provided October 4, 2019.You asked the Plan to pay forcode 23700. You say that you would like reconsideration based on the medical records provided.The Plan denied your request. The Plan says the submitted documentation does not indicate that manipulation under anesthesia, shoulder joint, including application of fixation apparatus was performed on the billed date of service.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 askedour coder 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 code 23700. Our reviewer says that code 23700 is not supported by the medical records. Our coder reviewer found the medical records provided do not include documentation of any manipulation under anesthesia, shoulder joint, including applications of fixation apparatus (dislocation excluded) being performed on October 4, 2019, therefore, the service cannot be verified. The medical record actually states, "no requirement for reduction".We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 23700 have not been met. Therefore, we decided that the Plan does not have to pay formanipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) (23700) provided October 4, 2019
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient hospital care provided to the enrollee from June 19, 2019 to June 24, 2019.You asked the Plan to pay forinpatient hospital care. You say that this was denied in error as you had an approved authorization for this date.The Plan denied your request. The Plan says that the day of June 20, 2019 was never approved.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regardingtheir decision to deny your request. The Plan has to make payment for the entire admission since there is no evidence provided to show that the entire stay was not medically necessary for the enrollee's condition.Therefore, we decided that the Plan hasto pay forinpatient hospital care provided to the enrollee from June 19, 2019 to June 24, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like to appeal the denial your physician wanted you to go to the skilled nursing facility. The Plan denied your request. The Plan says the enrollee's care can be managed at a lower level of care, such as discharge home with home health services including skilled therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the chest.You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 CT scan. Our reviewer says that a CT scan is not medically necessary. Our physician reviewer found there are no records that support a CT scan. No differential diagnosis is listed and tests such as 5-HIAA are negative.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the chest.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
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 Medicare coverage criteria have not been met. Our physician reviewer found an office note dated 1/22/20 documents normal strength and range of motion. The provider noted tenderness to palpation along the lower lumbar spine. The enrollee was noted had trialed physical therapy and anti-inflammatory medications. An MRI was ordered to evaluate for stenosis. Plain film imaging results were not included. The enrollee previously had an MRI of the cervical spine and lumbar spine on 10/15/19. The documentation does not support medical necessity of a repeat MRI study. 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 Lumbar Spine (72148).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 18, 2019 and October 19, 2019.
You asked the Plan to waive the copayment for the ED visits. You say that you weren't informed the emergency room doctor wouldn't remove the packing. You say that you shouldn't have to pay a second copayment. The Plan denied your request. The Plan says the copayments 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 $90 copayment for emergency services in an emergency room. You have been asked to pay a $90 copayment for each ED visit. The ED visits fall within the "Emergency care" benefit category. The records show that the ED visits were separate visits. 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 ED visit provided on October 18, 2019 and October 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
You asked the Plan to pre-approve SNF services. You say that you need rehab to be able to go home safely and do not feel ready. The Plan denied your request. The Plan says that you no longer require daily services in the inpatient skilled nursing facility setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the CT scan or the myelography provided
on August 30, 2019.
You asked the Plan to waive the copayments for the CT scan and the myelography. You say that these
copayments are too much. You say your copayments used to be $20.00. 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 $100
copayment per visit for CT scan/ultrasound and a $400 copayment for each Medicare-covered diagnostic
procedure and test in an outpatient facility.
You have been asked to pay a total of $214.71 for the CT scan and the myelography. The CT scan and the
myelography fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
August 30, 2019 CT scan $384.42 $100.00 $76.88 - This is
less than the
standard copayment
amount.
August 30, 2019 Myelography $689.14 $400.00 $137.83 - This is
less than the
standard copayment
amount.
Total $214.71
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 the CT scan or the myelography provided on August 30,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression devic
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis provided on June 6, 2019.You asked the Plan to pay forthe knee orthosis (L1833). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthosiswas not 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 pay for the knee orthosis (L1833). Our physician reviewer found the enrollee was seen for a regular follow-up visit. The documentation in the case file does not support that the requested knee orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is no objective documentation of joint laxity.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 knee orthosis (L1833) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis provided on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that you would like approval for this specialist office visit.The Plan denied your request. The Plan says you have been pre-approved for services with 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-approvea specialist office visit to be provided by an out of network(OON) provider.