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

We decided that the Plan does not have to pay for the Corona Virus testing provided by an international 
provider on April 17, 2021. 
 
You asked the Plan to pay for the Corona Virus testing. You say that you would like reconsideration because 
you required this testing for travel and were told you would be reimbursed. The Plan denied your request. The 
Plan says Corona Virus testing for travel is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Corona Virus testing have not been met. Specifically, the record does not show that a provider 
ordered this testing due to medical necessity. Corona Virus testing for travel is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the Corona Virus testing provided by an 
international provider on April 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on January 7, 2021 to January 16, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450/UB-04 hard copy form. We looked at the file and Medicare rules. The file shows that the claims were not billed on the required Form CMS-1450/UB-04 hard copy form. 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 home health services rendered on January 7, 2021 to January 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right-heart catheterization procedure (93451).
You asked the Plan to pre-approve a right-heart catheterization procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested procedure have not been met.
The Plan must follow Medicare rules. Medicare rules say that right heart catheterization is indicated to evaluate specific procedures as listed in the Medicare rules section of this letter.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a right-heart catheterization procedure have not been met. Specifically, the diagnosis provided is not an eligible diagnosis for coverage of a right-heart catheterization procedure. Therefore, we decided that the Plan does not have to pre-approve a right-heart catheterization procedure (93451).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patch.
You asked the Plan to pre-approve Fentanyl. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl patch.
Benefits for Fentanyl may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ExoDx Prostate IntelliScore, outpatient diagnostic 
test. 

You asked the Plan to pre-approve the ExoDx Prostate IntelliScor. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this test. 
 
The Plan must follow Medicare rules. Medicare rules say that each biomarker test is covered once in men 
greater than or equal to 75 years old prior to initial biopsy, with confirmed moderately elevated prostate 
specific antigen (PSA) (greater than or equal to 4 and less than 10 ng/mL) with both the criteria listed in the 
Medicare Rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ExoDx Prostate IntelliScor have not been met. Specifically, the enrollee's PSA level is greater 
than ten. Therefore, we decided that the Plan does not have to pre-approve the ExoDx Prostate IntelliScore, 
outpatient diagnostic test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker to be provided by a non-Medicare 
supplier. 
 
You asked the Plan to pre-approve the requested item. You say that you are unsafe on your current walker. The 
Plan denied your request. The Plan says the supplier does not accept Medicare. 
 
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 supplier in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve the requested item. Therefore, we decided that the Plan does not have to pre-approve an upright 
walker to be provided by a non-Medicare supplier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation to return to
their prior level of function before returning home safely. The Plan denied your request. The Plan says the
criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in a less
intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While
the documentation does support a need for physical and/or occupational therapy, there is no documented need
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 22, 2020, by an OON
provider.
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied
your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the office visit provided on October 22, 2020, by an OON
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided on April 5, 2021.
You asked the Plan to pay for surgical assistant services. You say that based on the payment indication list provided by Medicare, this procedure does not exclude an assistant-at surgery from payment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because surgical assistant services are not payable for this procedure code.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 19120. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for
surgical assistant services provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame/table system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this item is a convenience item and 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 a standing frame/table system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from February 24, 2021, to March 10, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that the injections were approved and you thought that you would only owe a $45 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on February 24, 2021. The total allowed amount is $365.74 and 20% of that is $73.15. You received Medicare Part B drugs on March 3, 2021. The total allowed amount is $365.74 and 20% of that is $73.15. You received Medicare Part B drugs on March 10, 2021. The total allowed amount is $365.74 and 20% of that is $73.15.
The total amount you owe is: $219.45. You have been asked to pay the total coinsurance amount of $219.45 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided from February 24, 2021, to March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on May 25, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because 
you were told that you would only owe a $50 copayment. 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 $225 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $225 copayment for an MRI. An 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 
an MRI provided on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has suffered with leg pain for years. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar distraction devices are experimental. More research is needed to show safety and efficacy of the devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laminectomy (63047) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the laminectomy. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers that can perform this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the laminectomy (63047) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment (E0431, E1390) provided March 18, 2021.
You asked the Plan to pay for the oxygen equipment. You say that the oxygen equipment was medically necessary. The Plan denied your request. The Plan says oxygen equipment is not covered for purchase.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers oxygen equipment for rental. Purchased oxygen equipment is not covered. We looked at the file and Medicare rules. The oxygen equipment was purchased. The plan approved rental of oxygen equipment and none was rented. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for oxygen equipment (E0431, E1390) provided March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on May 17, 2021.
You asked the Plan to pay for osseous surgery. You say that you were told by the Plan that this provider was in-network. The Plan denied your request. The Plan says this claim was processed correctly, and this provider is not part of your dental network.
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 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 $100 deductible for supplemental dental care. After this deductible is met, you are responsible for 50% coinsurance on the covered Plan allowance for major dental services (such as endodontics, periodontics, prosthodontics and oral surgery). You will save more money will you receive care from one of the Plan's in-network dental providers. You can get care from an out-of-network provider, but you may pay more. You have been asked to pay $929.50 for the osseous surgery. The provider billed the Plan $950 for this service. The Plan's allowance for osseous surgery is $141. You had not met your deductible at the time of service and were responsible for $100 of this amount before the Plan will pay their share of the cost. You are then responsible for 50% coinsurance on the remainder of the Plan's allowed cost for this service ($41 x 50% coinsurance = $20.50). An in-network provider is contracted with the Plan to accept the Plan's allowed cost as full payment for the service, but out-of-network providers do not have this agreement and are allowed to bill you the difference between the Plan's allowed cost for a service and the amount that was billed ($950 - $141 = $809). You are responsible for this difference in charges, your coinsurance, and your deductible ($809 + $20.50 + $100 = $929.50). 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 pay for the osseous surgery (D4261) provided on May 17, 2021.
Your complaint about potential misinformation from the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82274) provided on July 2, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (82274) provided on July 2, 2021.