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

We decided that the Plan does not have to pre-approve Freestyle Test Lite diabetic test strips.

You asked the Plan to pre-approve Freestyle Test Lite strips. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested items are not provided by a preferred vendor.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Test Lite strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Test Lite diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that your doctor recommended a shower chair for safety. The Plan denied your request. The Plan says shower chairs are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous
leukemia) translocation analysis services coded 81206 provided on September 14, 2020.
You asked the Plan to pay for the BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation
analysis services. 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 payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis services at issue in this
appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening
purposes. Therefore, we decided that the Plan does not have to pay for the BCR/ABL1 (t(9;22)) (e.g., chronic
myelogenous leukemia) translocation analysis services coded 81206 provided on September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the central motor evoked potential study services coded 95939, the short-latency somatosensory evoked potential study coded 95938 and 95927, and the needle electromyography services coded 95861 and 95868 provided on July 14, 2020.
You asked the Plan to pay for the central motor evoked potential study services, the short-latency somatosensory evoked potential study, and the needle electromyography services. 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. We find that CPT codes 95939, 95938, 95861, 95868 and 95927 are not supported in the medical record. Specifically, these services were billed with a place of service 15 (mobile unit). The documentation submitted shows that the enrollee was an inpatient at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the central motor evoked potential study services, the short-latency somatosensory evoked potential study, and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the central motor evoked potential study services coded 95939, the short-latency somatosensory evoked potential study coded 95938 and 95927, and the needle electromyography services coded 95861 and 95868 provided on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the documentation does not include a history or an examination or any other objective evidence to establish the medical reasonableness or necessity of the requested service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 13, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not timely filed.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until October 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 22, 2020.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite, one surface, anterior and the resin-based composite - three surfaces, posterior.
You asked the Plan to pay for the resin-based composites. You say that you thought you had the Plan's comprehensive dental benefit. The Plan denied your request. The Plan says you do not have the Plan's comprehensive dental benefit and these services are not normally covered.
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 pay for the resin-based composite, one surface, anterior and the resin-based composite - three surfaces, posterior.
Your complaint that you thought you were enrolled in the plan's comprehensive dental benefit 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the eye exams provided on November 11, 2019, and November 9, 2020.
You asked the Plan to waive the copay for the services provided. You say that the provider charged a refraction fee as part of a medical eye exam. The Plan denied your request. The Plan says the claim 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). Your contract with the Plan clearly says that you must pay a $30 copay for vision care. The file shows that you received a Medicare-covered eye exam on each date of service at issue. You have been asked to pay a $30 copay for the services provided. The services fall within the vision 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 copay for the eye exams provided on November 11, 2019, and November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and panoramic x-ray provided on December 15, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and panoramic x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says the calendar year maximum had been reached.
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 Plan offers a $500 combined allowance for supplemental preventive and comprehensive services every year. The contract clearly states that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit on August 26, 2020 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and panoramic x-ray provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair for the enrollee.

You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says that shower chairs are not primarily medical and therefore are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for transport services provided from August 18, 2020 to September 15, 2020.
You asked the Plan to pay for these transports. You say that these transports were medically necessary. The Plan denied your request. The Plan says you did not have prior authorization for transport by a non-plan provider.
Medicare does not cover routine transport. The Plan contract covers non emergent transportation with prior authorization. You did not have prior authorization the provider is not a plan provider. Therefore, we decided that the Plan does not have to pay for transport services provided from August 18, 2020, to September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiofrequency Ablation of the sacroiliac joint.
You asked the Plan to pre-approve Radiofrequency Ablation of the sacroiliac joint. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is experimental.
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 Radiofrequency Ablation of the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental because of the wide variation in efficacy in the peer reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Radiofrequency Ablation of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiofrequency Ablation of the sacroiliac joint.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for diabetic ketoacidosis, tremor and falls after recent COVID 19 infection. His medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that this 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 17, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the facility called for an ambulance because she fell. You say that she should not be responsible for the 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $220 copayment per one way trip for Medicare-covered ground or air ambulance services. The enrollee has been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 waive the copayment for the ambulance transport provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services on August 24, 2020.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 out of network services on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy to return home. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 a stroke. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 23, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you have gone to the emergency room several times and have never had to pay anything. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care. You have been asked to pay a $50 copayment for the emergency room visit. The 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 the emergency room visit provided on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.

You asked the Plan to pre-approve additional mileage. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your benefit.

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. The 51st mile and beyond is not a covered benefit. Your 2021 EOC says, "up to 24 one-way trips, combined in and out-of-network, are covered per calendar year (limited to ground transportation only). Each one-way trip must not exceed 50 miles of driving distance. A trip is one-way transportation; a round trip is 2 trips." Therefore, we decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and CT of the maxillofacial area provided on June 11, 2020.
You asked the Plan to pay for the panoramic x-ray and CT of the maxillofacial area. The Plan denied your request. The Plan says the panoramic x-ray is not a covered benefit. The CT of the maxillofacial area (code 70486) was sent to the medical policy because it is a medical code.
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 pay for the panoramic x-ray and CT of the maxillofacial area provided on June 11, 2020.