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

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure session will exceed the allowed limit of no more than two sessions per region of the spine in 12 months.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there have been radiofrequency procedures in the same area in March 2021 and most recently on September 22, 2021. No more than two radiofrequency sessions will be reimbursed per rolling 12 months. The current request exceeds the coverage guidelines for frequency. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1932). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need the requested item 
for work. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
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 you have a stationary oxygen concentrator. A stationary oxygen concentrator serves the 
same medical purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to 
pre-approve a portable oxygen concentrator (E1932).  
 
Your complaint about not receiving all ordered and necessary equipment from the DME supplier is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Provision of test materials and equipment for home INR monitoring (G0249).

You asked the Plan to waive the copayment for the home INR monitoring services. You say that this has been processed at a $45 copayment for other health care professionals instead of the correct code for Durable Medical Supplies of 20% coinsurance which amounts to about $18.46 per month. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 $45 copay for physician specialist services. 

You have been asked to pay $45 for the home INR monitoring services. The home INR monitoring services 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 copayment for Provision of test materials and equipment for home INR monitoring (G0249).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on May 6, 2020.

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 are not covered.

The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. The file shows that the testing was for 6 or more pathogens. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a breast biopsy (19083) provided on February 12, 2021; a CT scan of the abdomen (74170) provided on March 10, 2021; and a specialist office visit on May 17, 2021.

You asked the Plan to waive the copayments for a breast biopsy, a CT of the abdomen, and a specialist visit. You say that the charges at issue should be reconsidered. The Plan denied your request. The Plan says the correct copayments were applied.

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 $295 copayment for each Medicare-covered outpatient hospital facility visit; a $250 copayment for Medicare-covered diagnostic radiology services (not including X-rays, mammography, or ultrasounds); and a $30 copayment for each Medicare-covered specialist visit. You have been asked to pay a $295 copayment for a breast biopsy. A breast biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 

You have also been asked to pay a $185.32 copayment for a CT of the abdomen. A CT of the abdomen falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Finally, you have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay less than or equal to the correct amounts 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 a breast biopsy (19083) provided on February 12, 2021; a CT scan of the abdomen (74170) provided on March 10, 2021; and a specialist office visit on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves (A4927). 
 
You asked the Plan to pre-approve the non-sterile gloves. You say that you are 76 years old, and you need 
these items. The Plan denied your request. The Plan says the requested item are non-reusable, disposable 
supply items available in stores without a prescription. They are not primarily medical in nature. 
 
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 non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence garment, any type (A4520).

You asked the Plan to pay for incontinence supplies. You say that you have to get up 3 or more times to use the rest room. Changes has taken place in your bladder or whichever internal organs control your urination. You do not want to undergo surgery. The Plan denied your request. The Plan says incontinence garments are non-reusable supplies and listed as hygienic items that are not primarily medical in nature.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence garment, any type (A4520).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk assessment testing provided on April 1, 2021.
You asked the Plan to pay for genetic testing. You say that Medicare pays for these charges. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing panels for suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, 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 hereditary cardiovascular risk assessment testing provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom manual tilt-in-space manual wheelchair.
You asked the Plan to pre-approve these services. You say that the enrollee is at high risk for kyphosis and posterior pelvic tilt. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that these services is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a custom manual tilt-in-space manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT code 62323), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no active myotome and/or dermatome deficits as per the most recent examination. The magnetic resonance imaging (MRI) does not reveal significant nerve root compromise or evidence of a radiculopathy. In addition, aggressive conservative therapies have not been completed. The review has
determined that the requested epidural steroid injection is not 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT code 62323), for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on April 8, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 19, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on March 13, 2021.

You asked the Plan to waive this copayment. You say that you believe the Plan should waive this copayment. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 $250 copayment for each one-way ambulance transport.

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 charged for ambulance transport provided on March 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of an acute or subacute fracture in the records.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of any imaging that shows the fracture is less than six weeks old. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you thought the services would be covered. 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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798 provided on August 11, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798 provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and a tooth extraction (D7140) provided by an oral surgeon.

You asked the Plan to pre-approve a comprehensive oral evaluation and a tooth extraction. You say that you are allowed one tooth extraction per year. The Plan denied your request. The Plan says dental services must be provided by a participating doctor.

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. The requested dental service is not covered by your Plan dental benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and a tooth extraction (D7140) provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on May 26, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out-of-network physician services provided to the
enrollee on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the measurement of corneal curvature and depth
of eye provided on July 7, 2021.

You asked the Plan to waive the copay for these services. You say that you were not told there would be a
copay for these services. The Plan denied your request. The Plan says that the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay an $85
copay for each covered diagnostic procedure or test at a network doctor's office.

You have been asked to pay an $50.84 copay for these services. These services fall within the covered
diagnostic procedure or test at a network doctor's office benefit category. This means that you have been asked
to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copay for the measurement of corneal curvature and depth of eye provided on July 7, 2021.