Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the Plan does not cover out-of-network services except when it is emergency care or urgently needed services, or if Medicare requires the plan to cover the service and providers in the network cannot provide needed 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 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-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for outpatient services (CPT 67500) provided to the enrollee on December
17, 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 that this is denied because this surgical code was submitted by a provider with an anesthesia
specialty.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 67500 is "Retrobulbar injection; medication (separate
procedure, does not include supply of medication)."
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 reviewers says that the
services at issue in this case were not coded correctly. Our physician reviewer found the documentation
submitted was reviewed. This injection was given by a pain management group, and not related to the services
performed by another physician. The documentation is unclear as to additional procedures done on the same
date of 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 services have been met. Therefore, we decided that the Plan has to pay for
outpatient services (CPT 67500) provided to the enrollee on December 17, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the requested cannot be approved.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found you are not noted to have an inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or a walker). Therefore, this request is not medically reasonable or 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 the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation-diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310). You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy. 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a consultation-diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rest chair (E1399).You asked the Plan to pre-approve the rest chair. You say that you wanted a rest chair and your provider ordered a wheelchair. You do not want the wheelchair you want a rest chair because your current one feels uncomfortable.The Plan denied your request. The Plan says this item is not used to serve a medical purpose and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a rest chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy for the enrollee.You asked the Plan to pre-approve the therapy. You say that this is medically necessary.The Plan denied your request. The Plan says the type of treatment requested is not supported for this cancer type.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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard IMRT is an investigational question. Other treatment approaches (IMRT +/-IGRT) are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. Particularly with the use of a hydrogel spacer, the risk of GI/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more unlikely that there would be a potential benefit from proton therapy. To date, there are no compelling data to suggest that proton therapy 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, and to not routinely offer it to patients.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 therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve proton beam radiotherapy for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-skilled home health aide services.
You asked the Plan to pre-approve non-skilled home health aide services. You say that this is necessary due to the enrollee's depression. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered. We looked at fil, and Medicare rules. The records show that the requested services, which are non-skilled aide services for house cleaning, are custodial in nature. The records do not show that the enrollee has skilled nursing or therapy needs. Based on this information, we decided that Medicare rules for coverage of non-skilled home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-skilled home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested oral appliance.You asked the Plan to pre-approve the oral appliance. You say that there are no providers in-network that can provide the oral appliance.The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item.Therefore, we decided that the Plan does not have to pre-approve the requested oral appliance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on January 26, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was allowed on a different claim number.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Specifically, the record indicates that this claim is an exact duplicate of another that was previously processed and paid. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on January 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment formyocardial perfusion imaging provided on April 23, 2019.You asked the Plan to waive the copayment formyocardial perfusion imaging. You say that you disagree with 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 a $0 copayment for mammography and ultrasounds and a $270 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $270 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the 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 formyocardial perfusion imaging provided on April 23, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive and reduce some of the copayment and coinsurance for radiation treatment, CT scans and specialist office visits. We decided that the Plan does not have to fully waive and reduce the copayment and coinsurance for radiation treatment, CT scans and specialist office visits.
You asked the Plan to waive and reduce the copayment and coinsurance for radiation treatment, CT scans and specialist office visits. You say that the codes that you were originally given gave a total amount owed of $1,295. You say that your father then received a bill for $4,634.64. You say that this is not correct. The Plan says that the correct copayment has been applied.
We decided that the Plan has to waive and reduce some the copayment and coinsurance for radiation treatment, CT scans and specialist office visits.
The Plan follows Medicare rules. Medicare rules say that there is a $60 copayment for radiation therapy provided by in-network providers. Therefore, the 40% coinsurance for an out-of-network provider will be processed as in-network due to an in-network provider providing these services. The file shows that you have a medical indication for which Medicare will cover radiation therapy. Therefore, we decided that the Plan has to reprocess the April 11, 2019 out-of-network coinsurance to a $60 copayment for in-network radiation services. Also, services provided on April 1, 2019 to April 5, 2019 were denied; therefore, nothing is owed by the enrollee for these dates.
The total amount you are being asked to pay is $4,410.
Service
Copayment
Total Amount
Radiation
$60
$1,740 ($60 X 29)
CT Scan
$100
$2,600 ($26 x $100)
Specialist Office Visit
$35
$70 ($35 x 2 visits)
We also decided that the Plan does not have to waive and reduce all the copayment and coinsurance for radiation treatment, CT scans and specialist office visits.
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 $60 copayment for radiation treatment, a $100 copayment for a CT scan and a $35 copayment for specialist office visits. Therefore, we decided that the Plan does not have to waive and reduce all the copayment and coinsurance for radiation treatment, CT scans and specialist office visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). You asked the Plan to pre-approve the orthosis. You say that the enrollee suffered a stroke in October of 2015 resulting in right hemiparesis. Despite traditional therapies the enrollee's arm remains nonfunctional for completion of all ADL/IADL's. The Plan denied your request. The Plan says item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with related harness (E2377, E2313, and E2311), the arm pad (K0019), and the special desk arms, quad push button, tilt to drive feature, and seat to floor height bracket (four units of K0108).
You asked the Plan to pre-approve the additional power wheelchair options. You say that the requested accessories are all medically necessary and should be approved. The Plan denied your request. The Plan says the power wheelchair and accessories have been approved aside from certain components that cannot be separately billed.
The Plan must follow Medicare rules. Medicare rules say that power wheelchair components may be covered in accordance to the above noted criteria/guidelines. In this case, though the power wheelchair does have additional power components which could be accommodated through the expandable controller, these power components have their own independent switches. There is no documentation to show that the enrollee would be unable to use the dedicated switches for these power features. In addition, separately reporting the arm pads
with K0019 is not appropriate as arm pads are included in the reimbursement for the wheelchair itself. Lastly, the additional features being requested with K0108 are either already included in the power wheelchair base, or they are additional components of the expandable control which is not shown to be required in the documentation. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with related harness (E2377, E2313, and E2311), the arm pad (K0019), and the special desk arms, quad push button, tilt to drive feature, and seat to floor height bracket (four units of K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe urine-based genetic cancer risk test provided to the enrollee on April 30, 2019.You asked the Planto pay forthe test. You say that this should be paidfor.The Plandenied your request. The Plansaysthis test does not have proven benefit.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 test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the reviewed documentation does not include provider notes outlining the enrollee's history or the planned utilization of the requested test. Review of NCCN guidelines do not support this test for diagnostic evaluation. Without the support of the documentation, medical necessity cannot be determined.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 test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe urine-based genetic cancer risk test provided to the enrollee on April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need oxygen when you leave the house. The Plan denied your request. The Plan says that you currently have a stationary home oxygen concentrator and portable oxygen tanks for his oxygen needs within the home.
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 rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that you have a home oxygen concentrator with portable tanks. A home oxygen concentrator with portable tanks serves the same purpose as a portable oxygen concentrator. The portable oxygen concentrator 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 pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a calibrated gradient lymphedema pump and full length leg garments to be provided by an out of network provider.
You asked the Plan to pre-approve a calibrated gradient lymphedema pump and full length leg garments. You say that the enrollee was referred to you by a physician specializing in this specific equipment. The Plan denied your request. The Plan says the necessary 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 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 a calibrated gradient lymphedema pump and full length leg garments to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
You asked the Plan to pre-approve HBO therapy. You say that you need this service within a month of the onset of sudden idiopathic hearing loss. The Plan denied your request. The Plan says this is not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered only for the conditions listed above. We looked at the file and Medicare rules. The records do not show that you have a covered condition. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean extraction and consultation to be provided by an oral surgeon.You asked the Plan to pre-approvethe extraction and consultation. You say that a filling fell out, the tooth is breaking, and the nerve is exposed, causing you pain. You also say that you were referred to an oral surgeon for the extraction.The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not 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 itemsor services are not covered when they are provided by an oral surgeon.Therefore, we decided that the Plan does not have to pre-approvean extraction and consultation to be provided by an oral surgeon.