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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (MRI-TULSA).
You asked the Plan to pre-approve Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (MRI-TULSA). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 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 Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (MRI-TULSA). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had prostate cancer, now recurrent, that was treated with chemoradiation about 5 years ago. The medical records
indicates that the requested service is not a standard of care for the enrollee's condition. The requested service is still undergoing investigation for it's role in treating the enrollee's condition. The requested service is not medically reasonable and necessary, as defined by Medicare rules, for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (MRI-TULSA) have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (MRI-TULSA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided November 18, 2020.

You asked the Plan to pay for the complete upper and lower dentures. You say that you were not told that there were any requirements for which providers could be used. The Plan denied your request. The Plan says the provider has opted out of Medicare and therefore the services are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the complete upper and lower dentures have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided November 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic laboratory tests related to COVID-19 (U0004) provided July 31, 2020.
You asked the Plan to pay for diagnostic laboratory services. You say that you respectfully request the plan not penalize the lab for being out of network as you continue to do your part providing timely testing and results to
the COVID-19 pandemic. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for diagnostic laboratory tests related to COVID-19 (U0004) provided July 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on December 29, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you did not like the way
you were treated. You say that services that were rendered should not warrant a copayment. The Plan denied
your request. The Plan says the correct copayment has been 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 $120
copayment for emergency care.

You have been asked to pay a $120 copayment for an emergency room visit. The correct copayment has been
to the services that were provided. An emergency room visit 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 an emergency room visit provided by a participating
provider on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cooling cap (A9273) provided to you on November 30, 2020 to December 21, 2020.
You asked the Plan to pay for the cooling cap. You say that the services were necessary. The Plan denied your request. The Plan says they are unable to approve the request for reconsideration, but you will not be held responsible for the cost of the service.
The Plan must follow Medicare rules. Medicare rules say that this service is not paid for with a separate charge. Medicare considers cooling caps and other products for scalp cooling to be incidental to the chemotherapy administration and are not separately reimbursed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cooling cap have not been met. Therefore, we decided that the Plan does not have to pay for a cooling cap (A9273) provided to you on November 30, 2020 to December 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on December 15, 2020.
You asked the Plan to waive the copayment for ambulance transportation services. You say that you were never advised by your sales agent, the difference between Medicare Supplemental insurance and Medicare Advantage insurance. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $220 copayment for each one-way ambulance transport received out-of-network.
You have been asked to pay a $220 copayment for ambulance transportation services. The EOC confirms that $220 is the required copayment for this service. 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 ambulance transportation services (A0427) provided on December 15, 2020.
Your complaint about potentially receiving misinformation from a Plan sales agent 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighteen (18) additional miles for routine transportation.
You asked the Plan to pre-approve additional miles for routine transportation. You say that you are requesting eighteen (18) additional miles for routine medical appointments. The Plan denied your request. The Plan says this request exceeds your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at your request, the records in the case file, and the rules. Based on this information, this request exceeds your benefit limit because your 2021 EOC states each one-way trip must not exceed fifty (50) miles of driving distance. Therefore, we decided that the Plan does not have to pre-approve eighteen (18) additional miles for routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this request does not meet the coverage indication to be considered reasonable and
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found small cell prostate
cancer is not an indication for Keytruda. This should be denied as not reasonable and 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oximeter device for measuring blood oxygen levels non-invasively (CPT code E0445), for the enrollee.
You asked the Plan to pre-approve the oximeter device. You say that the oximeter device is necessary. The Plan denied your request. The Plan says the oximeter device is not covered by the Plan or Medicare.
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 oximeter device have not been met. The rules say that oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. Therefore, we decided that the Plan does not have to pre-approve oximeter device for measuring blood oxygen levels non-invasively (CPT code E0445), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

Explanation of decisionWe decided that the Plan does not have to pre-approvePOV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT code K0801).You asked the Plan to pre-approvethe POV. You say that you are not able to walk and have no support system at home. You state that the power wheelchair provided to you no longer fits you.The Plan denied your request. The Plan says your records do not document the necessary personal and home evaluations indicating this device meets but does not exceed your needs and that it is suitable for use in your home.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 POV. Our physician reviewer found you do have a personal mobility deficit, but it is not clear that this deficit impairs participation in MRADLs. You are able to ambulate with a cane and it is not clear why you cannot use a manual wheelchair. The documentation is not clear that you can safely maneuver the device in the home or that it will significantly improve your ability to participate in MRADLs in the home.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met.Therefore, we decided that the Plan does not have to pre-approvePOV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT code K0801).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from June
8, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our
physician reviewer found based upon review the records provided for the admission of this enrollee does not
meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 8, 2021,
forward as this enrollee was not shown to be a danger to themself or others. The enrollee was not showing any
auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats
the safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care from June 8, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on June 8, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 

We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for diagnostic mammography provided on March 8, 2021.

You asked the Plan to waive the co-payment for mammogram. You say that this imaging found nothing, and the technician told you that you should not have been called in. The Plan denied your request. The Plan says the co-payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co-payment for in-network diagnostic mammography at an outpatient hospital.

You have been asked to pay $50 co-payment for mammogram. Mammogram 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 co-payment for diagnostic mammography provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital visit provided on January 14, 2021.
You asked the Plan to waive the deductible for an outpatient hospital visit. You say that this was not a hospital visit, it was an office visit. The Plan denied your request. The Plan says the deductible you are being charged is correct.
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 $800 deductible for covered medical services.
The service at issue is subject to the Plan deductible of $800. The record shows that at the time this claim was processed, $0 of the $800 deductible had been met. The allowed amount of the claim is $146.85, resulting in a deductible obligation of $146.85. The record shows that the billing provider in this case was the hospital. The record also shows that the provider billed for a hospital visit, and not an office visit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time outpatient hospital visit was received on January 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient hospital visit (G0463) provided on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the full thickness graft (15260) provided on October 20, 2020.
You asked the Plan to pay for the full thickness graft. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per Medicare, the MUE for CPT code 15260 is 1 and 3 units have been billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 15260 is 1. You billed 3 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the full thickness graft have not been met. Therefore, we decided that the Plan does not have to pay for the full thickness graft (15260) provided on October 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the residential substance abuse services (room/board) provided from January 2, 2021, to January 3, 2021.
You asked the Plan to pay for the residential room/board services. You say that you provided a letter from the Medicare Administrative Contractor showing that you are enrolled in Medicare. The Plan denied your request. The Plan says the claim denied due to needing a Medicare ID number, as well as a Medicare Certification Letter, for processing and payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records does not support that this provider is enrolled as an inpatient hospital or psychiatric facility. The enrollment letter only shows enrollment as a clinic/group practice. There is no evidence that a Centers for Medicare and Medicaid Service Certification Number (CCN) was issued. We find
that the provider is not enrolled to provide the services billed in this case. Therefore, we decided that the Plan does not have to pay for the residential substance abuse services (room/board) provided from January 2, 2021, to January 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that through physical therapy you are now able to walk with a walker and you have gotten out of your wheelchair. You say that you know this is a slow process and although you are getting better, it takes time and without additional PT you believe that you will end up back in a wheelchair. The Plan denied your request. The Plan says your condition is no longer so complex that you require a therapist. The exercises should be continued on your own or with the help of non-therapists.
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 additional PT 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The therapy notes show that your primary limitation is endurance and ability to walk longer distances, which you can build up with a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.