Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on
October 27, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you were not aware that bitewing x-rays were
limited to once per year. The Plan denied your request. The Plan says bitewing x-rays are limited to twice per
calendar year, not to exceed 4 per year. The Plan also says that the benefit limit has been exceeded.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the bitewing x-rays have not been met. Specifically, the file shows that the benefit for bitewing xrays
has been exceeded. The file shows that the Plan paid for a set of 4 bitewing x-rays that you received on
May 4, 2021. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images
(D0274) provided on October 27, 2021.
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 these services. You say that the portable concentrator will help you with 
outside activities such as grocery shopping, doctor visits, activities with friends, and daily living. The Plan 
denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax (CPT)code S9999) from your purchase on July
2, 2021.
You asked the Plan to pay for the sales tax. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says sales tax is not covered.
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 sales tax have not been met. Sales tax is not covered.
Therefore, we decided that the Plan does not have to pay for the sales tax (CPT)code S9999) from your
purchase on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Accu-Check Aviva Plus test strips.
You asked the Plan to pre-approve the Accu-Check test strips.. You say that you would like reconsideration because you have been using the requested brand. The Plan denied your request. The Plan says you do not meet criteria for coverage of the non-preferred brand of test strips.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Accu-Check test strips. have not been met. Specifically, the documentation submitted does not include any clinical information to determine if the requested non-preferred brand of test strips is medically necessary. We are unable to verify if the criteria for coverage have been met. Of note, the record shows that the Health Plan made multiple attempts to obtain medical records but none were received. Therefore, we decided that the Plan does not have to pre-approve the Accu-Check Aviva Plus test strips
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left sacroiliac injection (27096).
You asked the Plan to pre-approve a left sacroiliac injection. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's previous injection did not provide sufficient relief.
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 left sacroiliac injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not have a meaningful improvement in her pain score from the previous left sacroiliac injection. 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 left sacroiliac injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a left sacroiliac injection (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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-approve compression stockings identified with code A6530.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for magnetic resonance imaging (MRI) of the abdomen and a computed tomography (CT) scan of the thorax provided on September 18, 2021.
You asked the Plan to waive the copayments for the MRI and CT scan. You say that you were informed that you would not be charged since your primary care doctor ordered the tests. 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 $295 copayment for CT scans performed by a provider other than your primary care physician. Your contract with the Plan also clearly says that you must pay a $295 copayment for all other diagnostic radiology services performed by a provider other than your primary care physician. You have been asked to pay $103.77, which is less than the $295 copayment for the MRI. You have also been asked to pay $49.14, which is less than the $295 copayment for the CT scan. The total for both tests is $152.91. The MRI and CT scan fall 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 copayments for magnetic resonance imaging (MRI) of the abdomen and a computed tomography (CT) scan of the thorax provided on September 18, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with
insulin. 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 pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery.
You asked the Plan to pre-approve 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 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. Therefore, we
decided that the Plan does not have to pre-approve a back-up battery
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the brain provided on July 14, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you have been trying to get the claims corrected with no assistance. 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 $175 copayment for diagnostic and nuclear medicine radiological services except X-rays and ultrasounds. 

You have been asked to pay a $175 copayment for the MRI. The MRI 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 for magnetic resonance imaging (MRI) of the brain provided on July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided on August 26, 2021.

You asked the Plan to waive the copayment for the physical therapy. You say that you have been going to this provider for 4 years and have never had a copayment before. 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 $10 copayment for each physical therapy (in-person or virtual) visit.

You have been asked to pay a $10 copayment for the physical therapy. Physical therapy falls within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy services provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this would help the enrollee to modify his diet and activity and improve blood glucose and weight. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional hours of neuropsychological testing evaluation services (96133)

You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the documentation does not support the additional hours requested.

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 neuropsychological testing evaluation services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this member's provider is asking for an excessive amount of the procedure beyond which is approved by the LCD. There is no documentation to support the excessive testing hours requested. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing evaluation services have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional hours of neuropsychological testing evaluation services (96133)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI).

You asked the Plan to pre-approve an MRI.. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 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 an MRI. Our reviewer says that the documentation supports that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has cervical radiculopathy that has failed conservative treatment with medical therapy including opiate, chiropractic therapy, massage therapy and acupuncture. The enrollee cannot tolerate physical therapy due to pain. The enrollee has undergone cervical spine film. The MRI of the cervical spine is indicated to plan injections and possible surgery. Therefore, the enrollee meets criteria for the requested MRI. Review of the file shows that the Plan uses Local Coverage Determination (LCD) L35175 to support their denial. However, LCD L35175 is not valid for the enrollee's home state of Illinois. Therefore, we cannot use LCD L35175 to substantiate our decision. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI. have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI).

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 hot tub.

You asked the Plan to pre-approve these services. You say that the hot tub is proven to provide low back pain relief. 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 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 hot tub.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision care services (92250, 92015, 92340, V2020)
provided on July 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for out-of-network vision care. You say that the enrollee does not have a choice in
providers because they reside in an assisted living facility. The facility coordinates care providers, and the
provider in this case was not responsible for obtaining authorization. The Plan denied your request. The Plan
says out-of-network care is only covered in limited circumstances. The services in this case were not urgent or
emergent, nor were they pre-approved or referred by a contracted provider.
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 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 vision care services (92250, 92015, 92340,
V2020) provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on July 5, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you are on social security and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit for Emergency Care. You have been asked to pay $63.73, which is less than the $90 copayment for the ER visit. ER visits fall 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 for an emergency room (ER) visit provided on July 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have serious pain when laying, sitting, or trying to sleep. One leg that is shorter and is affecting your quality of life. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit and services. You say that you have seen the list of doctors that the Plan gave you in your area and they cannot help you with your problem. The Plan denied your request. The Plan says there are network providers that can provide the requested 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 an office visit and services to be provided by an out-of-network (OON) provider