Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9363) provided on June 14, 2019 through June 30, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S9363 has a status code of I which is not valid for Medicare purposes.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 CPTcode S9363 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9363 has a status code of I. This means that S9363 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage ofthe home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9363) provided on June 14, 2019 through June 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.You asked the Plan to pre-approve routine transportation. You say that you are unable to obtain transportation to the providers office.The Plan denied your request. The Plan says routine transportation is not covered by your benefit plan.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Your plan does not offer routine transportation as a covered benefit.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approveroutine transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle.You asked the Plan to pre-approvea scooter. You say that because of a foot condition you are trapped in your home and cannot go outside.The Plan denied your request. The Plan says the need for a  scooter would be a temporary situation and you have a manual wheelchair that fits your needs.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. The file shows that your condition can be improved by your walker ormanual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in thisappeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home.Therefore, we decided that the Plan does not have to pre-approvea Group 2 standard poweroperated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.You asked the Plan to pre-approvea scooter. You say that you are unable to perform your routine daily activities and need assistance to walk.The Plan denied your request. The Plan says there is no physician order or face-to-face examination.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. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair or you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 1 standard power operated vehicle
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings/pants identified with code A6549.You asked the Plan to pre-approvethe compression stockings/pants. You say that the compression pants are medically necessary due to spinal stenosis and to aid in exercise  to limit lower extremity edema.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings/pants identified with code A6549.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an Electrocardiogram (93010) provided on May 29, 2019.
You asked the Plan to pay for the Electrocardiogram. You say that CPT 93010 was billed 3 times one the same
date of service by 3 different physicians. The Plan denied your request. The Plan says that duplicate claim lines
match a previous claim's member, provider, procedure code, modifier, date of service, quantity and billed
amount.
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 find that CPT code 93010 is supported in the record. Specifically, these claims were billed by different
providers and this is not a duplicate claim. Based on this information, we decided that Medicare rules for
coverage of the Electrocardiogram have been met. Therefore, we decided that the Plan has to pay for an
Electrocardiogram (93010) provided on May 29, 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient behavioral health services for the enrollee.
You asked the Plan to pre-approve the continued services. You say that the enrollee's risk factors are
exasperated by the enrollee's lack of family and social supports. The Plan denied your request. The Plan says
that there is no evidence of danger to self or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued services from January 20, 2020 forward were requested for the enrollee. 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 continued services. Our physician reviewer found that the
enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on with Schizoaffective
Disorder Bipolar Type. This enrollee was transferred from the emergency department because of delusions,
unpredictable and impulsive behavior. He was responding to internal stimuli and had gotten angry with the
group home manager. This enrollee was found to be actively psychotic, paranoid with poor eye contact and
irritability. He becomes violent and attacks his family. The enrollee does meet the criteria for treatment in an
acute inpatient mental health treatment beyond the date in question of January 20, 2020 forward. He could not
be treated in a lesser restrictive setting as although he was not showing any suicidal or homicidal ideation and
was not showing any behaviors being cooperative and compliant, he was actively being treated and did have
auditory hallucinations and delusions.
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 continued services have been met. Therefore, we decided that the Plan has
to pre-approve continued inpatient behavioral health services for the enrollee.
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 pay for test strips, lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2019 by out of network provider.You asked the Plan to pay for specialist services. You say that you would like to have this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available within 30 miles of the member's residence that could have rendered these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 11, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided September
27, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you do not feel that you
should have to pay this much for the only medication you take. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $229.20 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $1,146.00. ($1,146.00 x 20% = $229.20). The Part B injection falls within the "Medicare Part B
prescription drugs" 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 the Part B injection
provided on September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spine MRI (72148).
You asked the Plan to pre-approve a lumbar spine MRI (72148). You say that the requested lumbar spine MRI is medically necessary. The Plan denied your request. The Plan says the requested lumbar spine MRI is not medically necessary.
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 a lumbar spine MRI (72148). Our reviewer says that the requested lumbar spine MRI is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is noted to have back pain with subjective radiation into her buttocks and thighs. Thorough joint, spine and neurologic examinations have not been documented. While the enrollee was given steroids and narcotics, she does not appear to have been sent for lumbar x-rays or formal physical therapy/occupational therapy. It appears that the enrollee may have had a prior MRI, but when this occurred and what the formal radiology interpretation was is not known. The provided documentation is insufficient to show that the requested lumbar MRI is currently medically necessary or reasonable. 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 lumbar spine MRI (72148) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine MRI (72148).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from September 2, 2019
through September 30, 2019.
You asked the Plan to waive the coinsurance for dialysis. You say that you were not informed there would be
coinsurance for dialysis. You say that you don't agree with the charges. The Plan denied your request. The Plan
says the coinsurance 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). Your contract with the Plan clearly says that you must pay 20%
coinsurance for renal dialysis services.
You have been asked to pay $69.97, which is 20% of the allowed amount for each dialysis visit. The allowed
amount is $349.87 (20% x $349.87 = $69.97). The total amount you owe is $909.61 ($69.97/visit x 13 visits =
$909.61)
Dialysis falls within the "Services to treat kidney disease" 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 dialysis provided from September 2, 2019 through September 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 24, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you do not need the mammogram on your left breast. You say the plan is making you take this unnecessary 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 $25 copayment for Medicare-covered ultrasound at a freestanding provider. 
You have been asked to pay a $25 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ultrasound was indicated because of left breast cancer and a mastectomy in 1999. The record also shows you were only charged for the ultrasound.
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 ultrasound provided on July 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).You asked the Plan to pre-approve a CT of the abdomen and pelvis. You say that this is medically necessary.The Plan denied your request. The Plan says there are no signs or symptoms of disease in the pelvis.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 wascorrect in denying the request to pre-approve a CT of the abdomen and pelvis. Our reviewer says that a CT of the abdomen and pelvis is not medically necessary at this time. Our physician reviewer found the enrollee's needs can be met with CT scans of the chest and abdomen as the documentation does not show there is any disease in the pelvis.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 CT of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen and pelvis (74177)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on May 30, 2019.You asked the Plan to pay forthe ambulance mileage. You say that the charges for the ambulance were notcompletely covered and above the co-payment amount of $220.The Plan denied your request. The Plan says you are responsible for the additional mileage to the requested facility.The Plan must follow Medicare rules. Medicare rules say that Medicare only pays for air or ground transport to the nearest facility that meets the enrollee's medical needs. The plan has confirmed that the nearest hospital was 8 miles from your home. The hospital you requested transport to was 12 miles from your home.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance mileage have not been met.Therefore, we decided that the Plan does not have to payforthe non-covered ambulance mileage (A0888) provided on May 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac procedure provided on October 2, 2019.You asked the Plan to waive the copayment forthe cardiac procedure. You say that the procedure should be paid for by the insurance company. 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 $250 copayment for each outpatient surgery and/or service at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the cardiac procedure. The cardiac procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe cardiac procedure provided on October 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on July 2, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you feel like the ER did nothing and 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER 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 foran ER visit provided on July 2, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202) provided on August 26, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you are appealing the denial.The Plan denied your request. The Plan says the physician is an out-of-network provider. The Plan says that care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The Plan also says that the only type of coverage you can receive with an out-of-network provider is in urgent or emergent situations.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 foran office visit (99202) provided on August 26, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mouth guard.You asked the Plan to pre-approve the mouth guard.You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mouth guard have not been met. A Mouth Guard is only covered to treat obstructive sleep apnea. The medical records provided by your doctor do not show that you have obstructive sleep apnea.Therefore, we decided that the Plan does not have to pre-approvethe mouth guard