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

We decided that the Plan does not have to pre-approve implantation of the CardioMEMS system.You asked the Plan to pre-approve CardioMEMS. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is not enrolled in the Medicare Category B IDE study for CardioMEMS.The Plan must follow Medicare rules. Medicare rules say that Medicare may make payment for a Category B IDE as part of a Medicare-approved Category IDE study. We looked at the file and Medicare rules. There is a Category B IDE study for CardioMEMS, however the enrollee is not enrolled in this study at this time. CardioMEMS is not covered by Medicare outside of this Category B IDE study. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met.Therefore, we decided that the Plan does not have to pre-approve implantation of the CardioMEMS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe manual wheelchair provided to the enrollee from December 31, 2018 to October 31, 2019.You asked the Plan to pay forthe manual wheelchair. The Plan denied your request. The Plan says that this exceeds the frequency in which rental items can be billed.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the plan was already billed for a manual wheelchair during the same time you are requesting payment for. Since there was no authorization provided for the wheelchair rental and no claims were filed until September 2019, there is no evidence that the plan was made aware of the rental you provided prior to the receipt of the claims.Therefore, we decided that the Plan does not have to pay forthe manual wheelchair provided to the enrollee from December 31, 2018 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 8, 2018 to November 8, 2019 to the enrollee by an out of network (OON) provider. 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 the services were rendered by an out-of-network provider without prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the medical services provided on November 8, 2018 to November 8, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts and stabilizers.
You asked the Plan to pre-approve foot orthotics L3020 and L3170. You say that you need the orthotics. The
Plan denied your request. The Plan says these items are not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts and stabilizers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the light therapy lamp purchased on November 8, 2019.
You asked the Plan to reimburse you for the light therapy lamp. You say that the light therapy lamp was
recommended to you. The Plan denied your request. The Plan says therapeutic lightboxes are not covered by
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 light therapy lamp have not been met. Therefore, we decided that the Plan does not have to
reimburse you for the light therapy lamp purchased on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Electrodes (A4556) used during neuromonitoring performed October 11, 2019.
You asked the Plan to pay for the electrodes. You say that the service was medically necessary. The Plan denied your request. The Plan says the item was billed with a place of service other than the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. In this case, the electrodes were billed as DME but were used in the inpatient setting. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for Electrodes (A4556) used during neuromonitoring performed October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 2, 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 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 16, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you went to the hospital to be admitted but you say nothing was done at all and you left. 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 $90 copayment for each Medicare-covered emergency room visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the emergency room visit.You have been asked to pay a $63.67 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were evaluated by a provider during your emergency room visit. This means that you have been asked topay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room visit provided on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on September 25, 2019.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says that you did not
have services performed by a network optical provider.
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 covers these services when received from a network provider.
We looked at the file and the Plan's rules. The file indicates services were not received from a network optical
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have
not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided on
September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).You asked the Plan to pre-approve the PET scan. You say that the PET scan 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 PET is not covered for initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. Therefore, we decided that the Plan does have to pre-approve  a Positron Emission Tomography (PET) scan (78815).We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the upper GI endoscopies provided from June 19, 2019 and July 15, 2019.
You asked the Plan to waive the copayments for the upper GI endoscopies. You say that each test has been done in an outpatient hospital. You say you cannot afford the copayment for each test. 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 $150 copayment for each visit to an outpatient hospital facility. You have been asked to pay a $150 copayment for each of the upper GI endoscopies. The upper GI endoscopies falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the upper GI endoscopies provided from June 19, 2019 and July 15, 2019.
Appeal type: Imaging
Decision: Partially Favorable

You asked the Plan to pre-approve CT scan with contrast. You say that you feel this CT scan is prudent to ensure the resolution of the enrollee's pneumonia. The Plan says that the denial of authorization for this service is correct, because a repeat CT scan for community-acquired pneumonia is not necessary.
We decided that the Plan does not have to pre-approve the requested CT scan with contract. However, we also decided that the Plan has to pre-approve CT scan of the chest without contrast.
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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan with contrast, however the enrollee does meet Medicare criteria for a CT scan without contrast. Our physician reviewer found a follow-up chest CT scan is reasonable given the enrollee's complex medical history, but 1 month is not long enough to allow for clearing of the imaging abnormalities. The follow-up chest CT should be done no sooner than 2 months after pneumonia unless the enrollee relapses or has other interim reasons for imaging. This chest CT was ordered with contrast; however, it is suggested that the study be done without contrast in view of the enrollee's history of renal complications. A follow-up non-contrasted chest CT no sooner than April 21, 2020 is considered 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 CT scan without contrast have been met.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2 additional intraoral periapical x-rays provided on December 3, 2019.You asked the Plan to pay forthe dental services. You say that the Plan did not pay for D0220 and D0230. You say that under the criteria, the Plan should cover these services.The Plan denied your request. The Plan says they cover 4 intraoral periapical x-rays every 12 months. The Plan also says that this benefit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers adental 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 and intraoral periapical x-rays are a covered service, the benefit limit has been exceeded. The record shows that the Plan paid for 4 of the intraoral periapical x-rays that you received on December 3, 2019.Therefore, we decided that the Plan does not have to pay for2 additional intraoral periapical x-rays provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on October 11, 2019.
You asked the Plan to reduce the copayment for the office visit. You say that the provider is your primary care physician. You say that you were charged a $40 specialist copayment instead of $10. The Plan denied your request. The Plan says that the copayment applied correctly.
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 enrollees must pay a $10 copayment for each covered in-network primary care provider (PCP) office visit. The Plan says you must pay a $40 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the office visit. The records show that the provider is an internal medicine provider, which is considered a primary care physician. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on October 11, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 18, 2019 to November 16, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the CPT codes billed are not correct, per CMS guidelines, no RAP claim was found and the submitted claim does not include the necessary G and Q codes.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record does not include a RAP claim and the claim submitted does not include the required G and Q codes. Additionally, per the Physician Fee Schedule, CPT codes S9123 and S9127 have a status indicator of I, meaning they are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 18, 2019 to November 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered to the enrollee on September 24, 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 screening tests are not covered. 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 test at issue in this appeal, Cxbladder, was 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 Cxbladder testing rendered to the enrollee on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Monitoring (95999) provided on January 7, 2019.You asked the Plan to pay for the Train of Four Monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says separate payment of this service is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, Train of Four is considered a bundled procedure as it is integral to the primary procedure. Payment for Train of Four is included in the already approved neuromonitoring payment. Based on this information, we decided that Medicare rules for coverage of the Train of Four Monitoring have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four Monitoring (95999) provided on January 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair-accessible shower.
You asked the Plan to pre-approve a wheelchair-accessible shower. You say that wheelchair-accessible shower is medically necessary. The Plan denied your request. The Plan says a wheelchair-accessible shower is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover items such as wheelchair-accessible shower installations. Therefore, we decided that the Plan does not have to pre-approve a wheelchair-accessible shower.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy for enrollee.You asked the Plan to pre-approvethe requested services. You say that with IMRT, the volume of rectum receiving a high dose of grays would be more than 2 times greater.The Plan denied your request. The Plan says the requested services are not medically necessary for the enrollee.The Plan follows Medicare rules. Medicare rules say that proton beam radiotherapy is onlycovered under certain medical indications.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 requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Simply demonstrating that proton therapy will reduce the low dose to some normal tissues does not necessarily demonstrate that it is clinically superior to IMRT, as the reductions should be clinically meaningful, and reduce toxicity risks in a clinically meaningful manner. To date, there are no compelling data to suggest that protontherapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials.Therefore, the requested services are not medically reasonable or necessary.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy for enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance services(A0428) and ground mileage (A0425) provided on April 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ambulance service. You say that this was a medically necessary transport from a hospital to the enrollee's residence. Please reprocess this claim for a successful resolution. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 the BLS non-emergency ambulance services(A0428) and ground mileage (A0425) provided on April 15, 2019 by an out of network (OON) provider.