Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyewear provided on October 27, 2019.You asked the Plan to pay forthe eyewear. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan paid $100 for the eyewear and you are responsible for the remainder. Your EOC clearly states,you have an allowance of up to $100 every two (2) years for a combination of routine prescription contacts, routine prescription lenses, routine vision frames, and/or upgrades, such as tinting. This means the Plan will pay up to $100 every two years for routine vision hardware.Therefore, we decided that the Plan does not have to pay forthe eyewear provided on October 27, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).You asked the Plan to pre-approve the TTE. You say that these services are medically necessary.The Plan denied your request. The Plan says the nuclear stress testing is considered necessary; however, there is no need for a repeat TTE at this time.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 TTE. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is clinically stable. He has no symptoms of chest discomfort or CHF (Class I-II) at the current time. He is on a good medical regimen and his ICD has not discharged. He also had an echocardiogram one year ago which showed an EF of 37% but has had no intercurrent MI or changes in his symptoms. Given the lack of any change in symptoms (with none reported at rest or with exertion,) it is unlikely that his ejection fraction has decreased from the prior year. In addition, there is no indication on physical exam of worsening valvular heart disease which would be the other indication for a repeat echo at this time. Published guidelines do not recommend yearly routine assessment of LV function by echo in the absence of change in symptoms or intercurrent MI. Therefore the echocardiogram would not be considered medically reasonable or necessary at this time.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 TTE have not been met.Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the thoracic spine for  enrollee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have multiple sclerosis. There is no documentation of a change in symptoms or change in medication. Recent MRI of the cervical spine and brain have been completed and were non-actionable. The requested MRI of the thoracic spine is therefore not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the thoracic spine for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on November 14, 2019.You asked the Plan to waive the copayment foran office visit. You say that you disagree with the charges because this was your annual wellness visit.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 allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each visit with a primary care provider. The record shows that you had an office visit on November14, 2019. The claims were submitted with multiple diagnostic codes. Therefore, services beyond an annual wellness exam were rendered and 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 obligationyou agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided June 28, 2019 to August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 therapeutic exercises provided June 28, 2019 to August 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 5, 2019.You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.You asked the Plan to pre-approve Venofer. The Plan denied your request. The Plan says the provided clinical documentation shows no oral iron therapy has been tried and failed, which is a requirement before the IV infusion can be considered.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 Venofer. Our reviewer says that the service is not medically necessary. Our physician reviewer found the clinical notes from November 2019 and March 2020 do not support that the enrollee was taking an oral iron supplementation. Our reviewer found that the clinical guidelinessupportthat intravenous iron supplementation is appropriate when oral supplementation has failed or is otherwise contraindicated. Our physician reviewer also found that without the support of the documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of Venofer have not been met. Therefore, we decided that the Plan does not have to pre-approve Venofer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee by an out-of-network provider on August 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to obtain authorization before receiving services. The contract with the Plan says that outpatient rehabilitation services require prior authorization.The requested provider in this case is not a network provider with the Plan. The plan requires prior authorization for outpatient rehabilitation services. The Plan did not pre-approve the services at issue. The provider in question has been made aware that prior authorization is required. 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 forthe services provided to the enrollee by an out-of-network provider on August 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea repeat weight loss surgery (43644).You asked the Plan to pre-approvea repeat weight loss surgery. You say that you are at risk for a heart attack.The Plan denied your request. The Plan says the records do not show the first procedure failed or had complications.The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable and necessary but may potentially be covered when clinical circumstances demonstrate reasonability and necessity.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 repeat weight loss surgery. Our reviewer says that the criteria for coverage of a repeat weight loss surgery have not been met. Our physician reviewer found the is no documentation of any overt technical complications of your original bariatric procedure at this time. Reoperative surgery is not determined to be medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a repeat weight loss surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvea repeat weight loss surgery (43644).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the prophylaxis and complete series of
intraoral x-rays provided by an out-of-network provider on October 22, 2019.
You asked the Plan to waive the cost share for the prophylaxis and complete series of intraoral x-rays. You say
that there is not a dentist in your area that would consider doing these procedures for what the Plan allows. The
Plan denied your request. The Plan says the cost share for these services was applied correctly per your plan
benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived.
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, when using an out-of-network dentist,
you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided
that the Plan does not have to waive the cost share for the prophylaxis and complete series of intraoral x-rays
provided by an out-of-network provider on October 22, 2019.
Your complaint about being unhappy with the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the PSA test provided on November 24,
2019.
You asked the Plan to waive the copayment for the PSA test. You say that you don't know why you have a
copayment. 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 $20
copayment per visit for laboratory tests,
You have been asked to pay a $20 copayment for the PSA test. The PSA test falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The records show the PSA test was
ordered for diagnostic purposes. 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 PSA test provided on
November 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI services. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says the records do not show that the enrollee has failed to improve following a recent six week trial of doctor prescribed treatment shown by results of results of follow up contact with the doctor to look at the progress.
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 services. Our reviewer says that an MRI is not medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of several weeks of low back pain radiating to right leg. There are no red flag findings on physical examination. There is no documentation of prior trial of conservative therapy such as physical therapy. There is no documentation of a plan for urgent surgical intervention. The stated differential is discogenic pain versus peripheral artery disease. The diagnostic plan was MRI of the lumbar spine, plain x-rays and ankle-brachial index (ABI) of lower extremities. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.
You asked the Plan to pre-approve the sleeve. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that as a mastectomy sleeve does not meet the definition of a prosthesis, it is not covered. Medicare does not consider the requested sleeve to be a coverable prosthesis. Based on this information, we decided that Medicare rules for coverage of the sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe  office visit, evaluation of wheezing, pulmonary function test, and C02 membrane diffuse capacity services provided on October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese out of network services.You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.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 forthe  office visit, evaluation of wheezing, pulmonary function test, and C02 membrane diffuse capacity services provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 10, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene testing provided to the enrollee on July 19, 2019 with
diagnosis code C34.31 and codes 81235, 81210, 81275 and 81276.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria for this testing were not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. In this case, the
diagnosis code reported, C34.31, is listed as a covered diagnosis code however codes 81235, 81210, 81275 and
81276 are not listed as covered codes. Medicare billing criteria are not met. Therefore, we decided that the Plan
does not have to pay for gene testing provided to the enrollee on July 19, 2019 with diagnosis code C34.31 and
codes 81235, 81210, 81275 and 81276.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on May 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 20931 is not supported.
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 20931 is allograft, structural, for spine surgery only (List separately in addition to code for primary procedure). We find that CPT code 20931 is not supported in the medical record. Specifically, the operative report does not support that a structural allograft was used. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on May 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a nerve conduction study provided on October 11, 2019.
You asked the Plan to pay for the nerve conduction study. The Plan denied your request. The Plan says services provided by non-participating providers are excluded from coverage.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a nerve conduction study provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like the appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an office visit provided on November 25, 2019 by an out of network (OON) provider.