Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this treatment is still being studied to see if is medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental/investigational procedure that is the subject of on-going clinical trials. 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a platelet rich plasma injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 19, 2020 and July 6, 2020.You asked the Plan to pay for the physician's 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 servicesat 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 physician's services providedon June 19, 2020 and July 6, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe UPWalker Lite.You asked the Planto pre-approvethe walker. You say that this is medically necessary, as it would allow you walk without having to bend over.The Plandenied your request. The Plansaysthis is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the walker. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that this device improves participation of MRADLs in the home more than a standard walker or has improved long term safety or efficacy over a over a standard walker for your 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 the walker have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe UPWalker Lite.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgently needed services provided by a
specialist on October 27, 2020.
You asked the Plan to reduce the copayment for the urgently needed services provided by a specialist. You say
that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider
your request. The Plan denied your request. The Plan says you received urgently needed services provided by a
specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per
your contract with the Plan.
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 each covered office visit to other providers for urgently needed services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received urgently needed
services provided by a specialist on October 27, 2020. You have been asked to pay a $40 copayment for the
urgently needed services provided by a specialist. The urgently needed services provided by a specialist falls
within the Urgently needed 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 reduce the copayment for
the urgently needed services provided by a specialist on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on August 14,
2020.
You asked the Plan to waive the copayment for the mammogram. You say that it is a law that a person with a
history of breast cancer is entitled to a screening mammogram and ultrasound with no cost. 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 $25
copayment for other Medicare-covered outpatient diagnostic procedure and tests.
You have been asked to pay a $25 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a
personal history of breast cancer which makes the mammogram 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 mammogram provided by on August 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation services provided by your caregivers from June 29, 2020, through July 9, 2020.You asked the Plan to pay forthe transportation services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are transport services to a doctor's office.Therefore, we decided that the Plan does not have to payforthe transportation services provided by your caregivers from June 29, 2020, through July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eternal formula (CPT Code B4152).
You asked the Plan to pre-approve the eternal formula. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says eternal formula by mouth is not a covered benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the eternal formula have not been met. Eternal formula by mouth is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve eternal formula (CPT Code B4152).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient back surgery provided from October 28, 2020, to October 29, 2020.You asked the Plan to waive the copayment forthe outpatient back surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient backsurgery on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $350 copayment for Outpatient surgery.We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient back surgery from October 28, 2020,to October 29, 2020. You have been asked to pay a $350 copayment for the outpatient back surgery. The outpatient back surgery falls within the Outpatient surgery 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 forthe outpatient back surgery provided from October 28, 2020, to October 29, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nephrology office visit (99205) provided March 2, 2020.

You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says this was an in-person visit and the correct copayment 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 $30 copayment for specialist visits. 

You have been asked to pay a $30 copayment for the nephrology visit. This office visit falls within the specialist 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 a nephrology office visit (99205) provided March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 relevantMedicare 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 based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea retainer crown (D6720) and pontic (D6240).You asked the Plan to pre-approvea crown and pontic. You say that the services should be covered and are medically necessary.The Plan denied your request. The Plan says the services are not covered under your benefit 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. Specifically, the services requested are not listed in the Plan's benefit chart. This means the services are not covered under your benefit plan.Therefore, we decided that the Plan does not have to pre-approvea retainer crown (D6720) and pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bridge (D6750, D6240 and D6250).You asked the Plan to pre-approvea bridge. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generallydoes 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. The Plan covers a bridge when the services are medically necessary and reasonable. 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 bridge. Our reviewer says that the service is not medically necessary. Our physician reviewer found according to the criteria for coverage, fixed bridges are covered to replace anterior teeth when no posterior teeth are missing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a bridge have not been met. Specifically, bridges for posterior teeth are not covered.Therefore, we decided that the Plan does not have to pre-approvea bridge (D6750, D6240 and D6250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from April 16,
2020, to May 21, 2020.
You asked the Plan to pay for home infusion therapy. You say that this was medically necessary. The Plan
denied your request. The Plan says this was not billed with a valid code.
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 S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
April 16, 2020, to May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services providedon August 11, 2020.You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says you 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 planMedicare 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 servicesat 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 surgical pathology services providedon August 11, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided.

You asked the Plan to pay for the x-ray services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed..

The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 

We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay for the x-ray services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forDRG 190 for Sepsis for services provided on June 6, 2020, through June 15, 2020.You asked the Plan to pay forDRG 190. You say that you would like reconsideration because DRG 190 is supported by the record.The Plan denied your request. The Plan says DRG 190 is not supported by the medical records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.Providers must report inpatient hospital services with the appropriate DRG. DRG 190 is defined as  Chronic Obstructive Pulmonary Disease with MCC.In this case, you billed the services provided June 6, 2020, through June 15, 2020 with DRG 190. 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 DRG 190. Our reviewer says that the documentation did not support the DRG for Sepsis. Our physician reviewer found Sepsis is not clinically validated and documentation does not support evidence of organ dysfunction/failure by a dysregulatedresponse to infection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 190.Therefore, we decided that the Plan does not have to pay forDRG 190 for Sepsis for services provided on June 6, 2020, through June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex surgery (22869).You asked the Plan to pre-approvethe Vertiflex surgery. You say that this service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says this procedure is not reasonable or necessary.The Plan must follow Medicare rules. Medicare rules say that items and servicesthat are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device to be used as part of the Vertiflex surgery is experimental. More research is needed to show safety and efficacy of the device.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 Vertiflex surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex surgery (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea semi-electric variable height hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical criteria were not met to be covered as medically necessary.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found your condition does not require positioning ofthe body in ways not feasible in an ordinary bed. You do not require frequent changes in body position. There is no need for immediate changes in body position. Your condition does not require special attachments that cannot be fixed and used on an ordinary bed. A semi-electric hospital bed 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 the bed have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea semi-electric variable height hospital bed
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 enrollee has active DC orders and is at a hospital actively on diversion. You say that the enrollee requires a minimum of 3 hours of therapy daily. You say that IRF care is medically necessary to provide the enrollee with the quality treatment and management needed to access his physical abilities adequately. The Plan denied your request. The Plan says the guidelines for coverage of care in an IRF 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure, lymphedema and kidney disease. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 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.