Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD) (E0483).You asked the Plan to pre-approvea HFCWOD. You say that the HFCWOD is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the HFCWOD is not medically necessary. Our physician reviewer found the enrollee has COPD and a permanent tracheostomy. There is a history of aspiration pneumonia. The enrollee does not havegeneralized neuromuscular disease, cystic fibrosis, or bronchiectasis. There is no convincing clinical evidence that HFCWO is beneficial in COPD. Moreover, HFCWO could increase the risk of aspiration of gastric contents.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 HFCWOD have not been met.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services with an out-of-network provider.You asked the Plan to pre-approvethe services. The Plandenied your request. The Plan says the services are available in-network.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visits provided on March 26, 2020 to April 9, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visits. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foroffice visits provided on March 26, 2020 to April 9, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the mammogram provided on March 10, 2020.
You asked the Plan to waive the copayment the mammogram. You say that you never told any doctor you were having any issues or pain in your breast. You say you want the copayment removed. 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $40 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows that the reason for exam was breast tenderness. Therefore, the mammogram was 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 the mammogram provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe total electric hospital bed, with any type side rails, with mattress (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that the enrollee is on a trach and requires frequent repositioning and is taken care of by his mother who is unable to physically crank a bed and position the enrollee without the assistance of the fully electric bed.The Plan denied your request. The Plan says this item is not covered.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-approvethe total electric hospital bed, with any type side rails, with mattress (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four gingivectomies or gingivoplasties (D4210 x4).
You asked the Plan to pre-approve the gingivectomies or gingivoplasties. You say that urgent care is needed
due to several issues. You also say that your lips are swollen due to your gums being swollen. The Plan denied
your request. The Plan says this service is not a covered benefit.
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. Therefore, we decided that the Plan does not have to pre-approve four
gingivectomies or gingivoplasties (D4210 x4).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Acetaminophen tablets provided on February 24, 2020.
You asked the Plan to pay for the Acetaminophen tablets. You say that you were in the hospital for Remicade infusion. You also say that you did not know you would get a bill. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Acetaminophen tablets provided on February 24, 2020.
Benefits for the Acetaminophen tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty wheeled walker with a seat (E0147). You asked the Plan to pre-approve the heavy duty walker. You say that the records provided should support the necessity of the item in dispute.The Plan denied your request. The Plan says the enrollee does not meet the medical necessary criteria for the heavy duty wheeled walker with seat.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 heavy duty walker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not document the enrollee meets criteria as detailed below for the walker, heavy duty, multiple braking system, variable wheel resistance. Obesity, by itself, is not a sufficient reason for an E0147 walker.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 heavy duty walker have not been met.Therefore, we decided that the Plan does not have to pre-approve the heavy duty wheeled walker with a seat (E0147).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethree core buildups, including any pins when required (D2950 x3).You asked the Plan to pre-approvethe core buildups. You say that the enrollee currently has very large existing fillings and deep recurrence decay.The Plan denied your request. The Plan says this service is not a covered benefit.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.Therefore, we decided that the Plan does not have to pre-approvethree core buildups, including any pins when required (D2950 x3)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 26, 2019.
You asked the Plan to pay for the ambulance transport from dialysis. You say that the transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport from dialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport from dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 12, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on July 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinversion table for vertebral axial decompression (E0941).You asked the Plan to pre-approvethe inversion table. You say that you had an inversion table 30 years ago and it worked to relieve your back pain. You've had multiple surgeries and no relieve and was told nothing more can be done to relieve your back painThe Plan denied your request. The Plan says this is not a covered benefit under Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inversion table have not been met.Therefore, we decided that the Plan does not have to pre-approveinversion table for vertebral axial decompression (E0941)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS 3D brush biopsy provided to the enrollee on
December 10, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says morphometric analysis maybe considered medically necessary to analyze known cancer tissue
and bone marrow biopsies when it is expected that the results will impact treatment decisions.
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 pay for the services. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found while it
is speculated that WATS 3D biopsy testing can potentially improve the management and improve outcomes of
patients with Barrett's esophagus and esophageal dysplasia, there is not high-quality evidence in the medical
literature demonstrating that such testing improves the management and outcomes of such patients. The
documentation does not support that the WATS 3D biopsy testing was medically reasonable and necessary for
the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for WATS 3D brush biopsy provided to the enrollee on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on February 27, 2020.
You asked the Plan to pay for the perfusionist services. You say that the charges are for the perfusionist that
setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan
says payment for the service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the
beneficiary either directly or under arrangements made with outside providers. This service was provided via
arrangement of the facility. Payment for this service would have been included under the facility claim.
Payment to you for this service is the responsibility of the facility. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the perfusionist services provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe certolizumab injections provided from January 3, 2020 to January 31, 2020.You asked the Plan to waive the coinsurance forthe certolizumab injections. You say that you were told the injections would be free of charge because you cannot afford the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs (including certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps). You have been asked to pay a total of $1,313.60for the certolizumab injections. The certolizumab injections fall within the "Medicare Part Bprescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with thePlan. 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 coinsurance forthe certolizumab injections provided from January 3, 2020 to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist physician services provided on August 6, 2019.
You asked the Plan to pay for the physician services. You say that the enrollee has not seen any other provider of this specialty in the past 3 years. The Plan denied your request. The Plan says the services were processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copay for specialist services. The file shows that the billed office visit has been paid for by the plan based on the Medicare-allowed amount. The enrollee has been asked to pay a $40 copay for the specialist services. The services fall within the physician services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for the specialist physician services provided on August 6, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for room and board hospice facility services provided from September 1, 2019 to September 20, 2019.
You asked the Plan to pay for the room and board hospice facility services. The Plan denied your request. The Plan says Medicare guidance says code T2046 has a status code of "I."
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 room and board hospice facility services provided from September 1, 2019 to September 20, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe wheelchair van transportation provided on May 29, 2019.You asked the Plan to pay forthe wheelchair van service (A0130). You say that you told the Plan that their provider was unable to accommodateyou but the Plan did not provide transportation so you arranged your own.The Plan denied your request. The Plan says that youdid not meet criteria for ambulance transportation.Medicaredoes 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. The Plan coverswheelchair van services (A0130) to plan-approved locations with a distance of 60 miles per one-way trip.We looked at your request, the records in the case file, and the rules. You requested ambulatory transportation for edema treatment. The recordshows you used a wheelchair van transport service after trying to schedule with the Plan's provider who was unable to accommodate you. The Plan did notthencoordinate your care under your Routine Transportation benefit.Based on this information, we decided that the Plan's rules for coverage of the wheelchair van (A0130) have been met.Therefore, we decided that the Plan has to pay forthe wheelchair van transportation provided on May 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the kidney stone surgery provided on January 14, 2020.
You asked the Plan to waive the copayment for the kidney stone surgery. You say that you are financially helpless. 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 $275 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $275 copayment for the kidney stone surgery. The kidney stone surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 kidney stone surgery provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).You asked the Plan to pre-approvethe mandibular partial denture. You say that providing a mandibular partial denture to the enrollee is a standard of care.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, mandibular partial dentures are limited to one procedure every five plan years. The record shows that the enrollee received a mandibular partial denture (D5214) on September 1, 2015 and the enrollee's mandibular partial dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).