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

We decided that the Plan does not have to pre-approve an automatic home blood pressure monitor. 
 
You asked the Plan to pre-approve an automatic home blood pressure monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to preapprove an automatic home blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on February 21, 2020 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you had this appointment scheduled months in advance and the office failed to inform you that they were no longer in the network.The Plan denied your request. The Plan says you do not have out-of-network benefits.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.Review of the file show that you received the dental services on February 21, 2020 provided by an out-of-network provider. Your EOC states, enrollees must pay 100% for out-of-network dental benefits. 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 dental services provided on February 21, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation treatment.
You asked the Plan to pre-approve inpatient rehabilitation treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 inpatient rehabilitation treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 7, 2020 forward as this enrollee was not shown to be a danger to herself or others. She was not showing auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any symptoms of alcohol withdrawal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on January 3, 2020.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says CPT 87633 is not covered by Medicare and is excluded from coverage.
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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) identified with
code E0675.
You asked the Plan to pre-approve a PCD. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PCDS coded E0675 is non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
pneumatic compression device (PCD) identified with code E0675.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve eyebrow repair surgery.
You asked the Plan to pre-approve the surgery. You say that this is not a cosmetic issue and you want to be able to see well again. The Plan denied your request. The Plan says that this may not address the enrollee's physical issue.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found in this situation, it is clear that you have left brow ptosis, as evidenced by photographs with commensurate lid margin ptosis. The physical examination demonstrates MRD that does not meet criteria for coverage, however visual field tests are consistent with a functional deficit. Medicare LCD criteria allow for exception to the MRD criteria when there is compelling evidence of functional disability based on history and visual field information. The visual fields, history and photographs are compelling evidence of functional disability in spite of the MRD measurements that do not meet criteria. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve eyebrow repair surgery.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MPI SPECT (78452).
You asked the Plan to pre-approve a MPI SPECT (78452). You say that the requested MPI SPECT is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested MPI SPECT.
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 a MPI SPECT (78452). Our reviewer says that the enrollee does not meet criteria for the requested MPI SPECT. Our physician reviewer found the enrollee is with a history of hypertension, diabetes, dyslipidemia, esophageal reflux, stroke and coronary artery disease including myocardial infarction. Cardiac catheterization 12/28/2018 reported a patent LAD stent and a known chronic total occlusion of the RCA with left-to-right collaterals, medically managed. An echocardiogram 03/2020 reported normal ventricular function. Poor exercise tolerance on an ETT 04/06/2020 is reported, but no chest pain or ischemic ECG changes at the reduced workload achieved. A clinic note dated 04/13/2020 documents no chest pain, no dyspnea and a normal cardiovascular physical exam. Based on the records the enrollee has known coronary disease with last catheterization < 2 years ago and clinically stable since then with no chest pain, no dyspnea, normal cardiac physical exam, normal LV function on echo and no ischemia on a limited exercise treadmill test. In this circumstance of a stable patient < 2 years from prior catheterization the records do not support the medical necessity for nuclear stress testing. Coverage criteria is not met since the enrollee is asymptomatic, clinically stable and not > 2 years from prior coronary evaluation. 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 MPI SPECT (78452) have not been met. Therefore, we decided that the Plan does not have to pre-approve a MPI SPECT (78452).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve OON mental health services.. You say that there are not many psychiatrists
in your area and this provider has treated your family. The Plan denied your request. The Plan says there are in network providers available for 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SPECT test provided on February 27, 2020.
You asked the Plan to waive the copayment for the SPECT test. You say that you were not aware that there
would be a copayment for the test you had done. 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 per visit for Medicare-covered services.
You have been asked to pay a $150 copayment for the SPECT test. The SPECT test falls within the per visit for
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the SPECT test provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided on March 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for these services is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on December 20, 2019.
You asked the Plan to waive the coinsurance for an office visit. You say that you met the MOOP amount for the year and should not be responsible for the charges. 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 all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for physician/practitioner services, including doctor's office visits. You had an office visit on December 20, 2019. The record shows that you had only paid $887.10 toward the $910 MOOP amount prior to receiving the services. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $114.49 and 20% of that is $22.90. You have been asked to pay the total coinsurance amount of $22.90 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 obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an office visit provided on December 20, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe Compass Blood Evaluation Myeloid Molecular Profile rendered on October 23, 2019 to November 6, 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 that the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met.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 these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of other pancytopenia. He has multifactorial anemia, and a diagnosis of myelodysplasia is being considered. A bone marrow study was obtained. Fluorescent in situ hybridization (FISH) of bone marrow or peripheral blood can be useful for confirmation of the diagnosis of hematologic malignancies such as leukemias, myelodysplastic syndromes, myeloproliferative neoplasms, and lymphomas. The testing was reasonable and 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 these services have been met.Therefore, we decided that the Plan has to pay forthe Compass Blood Evaluation Myeloid Molecular Profile rendered on October 23, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure ventilation coded 94660, the nasal interface coded A7034, the tubing coded A7037, the filter coded A7039, and the filter coded A7038 provided on October 9, 2019.
You asked the Plan to pay for the continuous positive airway pressure ventilation, the nasal interface, the tubing, and the filters. 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 94660, A7034, A7037, A7039, and A7038 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of continuous positive airway pressure ventilation (CPAP), initiation and management was performed; therefore, code 94660 is not supported. The documentation submitted did not include a valid physician order; therefore, codes A7034, A7037, A7039, and A7038 are not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the continuous positive airway pressure ventilation, the nasal interface, the tubing, and the filters have not been met. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure ventilation coded 94660, the nasal interface coded A7034, the tubing coded A7037, the filter coded A7039, and the filter coded A7038 provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 16, 2020 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you believed you were in urgent need of dental services, and the in-network providers listed during a phone call on January 15, 2020, were either too far away to visit or couldn't set up appointment in a reasonable amount of time (30 days).The Plan denied your request. The Plan says review of the call logs to two in-network providers located in your area stated you would have been able to schedule an appointment for the date of service January 16, 2020.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.Review of the file show that you received the dental services provided on January 16, 2020 by an out-of-network provider. Your EOC states, to be covered in-network, you need to use a provider that is contracted with the dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of the supplemental dental network is not covered. 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 dental services provided on January 16, 2020 by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient surgery provided on January 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forinpatient surgery. You say that these services should be covered.The Plan denied your request. The Plan says these services were not authorized.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. The records show that pre-authorization was requested and denied. 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 inpatient surgery provided on January 3, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transport provided on November 24, 2019.You asked the Plan to pay forthe non-emergent transport. You say that the Plan should pay this claim.The Plandenied your request. The Plan says you did not request prior authorization.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.Prior authorization was not requested.Based on this information, we decided that Medicare rules for coverage of the non-emergent transport have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance transport provided on November 24, 2019.