Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the required information was not received.
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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested monitor is not considered therapeutic. The enrollee has not been using insulin three or
more times per day. The enrollee's treatment does not require frequent adjustment on the basis of testing
results.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87496, 87498, 87798,
87486, 87541, 87581, 87640) provided to the enrollee on May 14, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code(s): 87496, 87498, 87798, 87486, 87541, 87581, 87640 remain not supported. The place of service on
the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office
setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 14, 2020,
and received by the lab on May 15, 2020. Of note, the enrollee resides in New Jersey and the billing laboratory
is located in Texas; therefore, the billed code cannot be verified. It is noted multiple attempts were made to
obtain additional information from the provider. 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 (CPT code(s): 87496, 87498, 87798, 87486, 87541, 87581, 87640) provided to the
enrollee on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 16, 2021 and March 3, 2021.
You asked the Plan to pay for the dental services. You say that you are filing for your $300 toward your comprehensive dental services. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 16, 2021 and March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on March 11, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor (CGM) supplies rendered on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot surgery you had at an ambulatory
surgery center on March 3, 2021.
You asked the Plan to waive the copayment for the foot surgery. You say that you should not have to pay this
copayment because the surgery was not successful. The Plan denied your request. The Plan says you were
charged this copayment 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 a $250
copayment for surgical services in an ambulatory surgery center.
You have been asked to pay a $250 copayment for the foot surgery. The foot surgery falls within the surgical
services in an ambulatory surgery center 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 the foot surgery you had at an ambulatory surgery center on March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; of the retina (92134), the ophthalmological medical examination and evaluation (92012), and the ophthalmoscopy (92201) provided on February 18, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 $45 copayment for specialist physician services. Additional cost-sharing applies for diagnostic and radiology services received at physician offices. Enrollees pay a $50 copayment for all other Medicare-covered outpatient diagnostic tests. You have been asked to pay $88.16 which includes a $45 copayment for the physician specialist services provided. Additionally, this includes the Plan allowed amount of $43.16 for the Medicare-covered diagnostic tests provided, which is less than the applicable copayment. Additional cost-sharing applies for diagnostic and radiology services received at physician offices. 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 cost share for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; of the retina (92134), the ophthalmological medical examination and evaluation (92012), and the ophthalmoscopy (92201) provided on February 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99202 and 97124) provided from March 22, 2021, to March 30, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services billed by your provider are not related to manual manipulation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (99202 and 97124) provided from March 22, 2021, to March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on September
10, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you were told you would
not have to pay anything for this service. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that because the allowed amount for this service ($76.17) is less than your
copayment obligation, you are responsible for the full allowed amount. The Plan also says that there are no
records of you calling the Plan at any time between January 1, 2020, and September 10, 2020.
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
copayment for radiological diagnostic services, including ultrasounds.
You have been asked to pay a $100 copayment for the breast ultrasound. The breast ultrasound falls within the
radiological diagnostic 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
the breast ultrasound you had on September 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessories (E0673) provided on March 15, 2021.
You asked the Plan to pay for a pneumatic compression device and accessories. You say that this was billed correctly. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as E0675 to treat peripheral artery disease (PAD) is not eligible for reimbursement. PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage criteria for that type of PCD. We looked at the file and Medicare rules. The pneumatic compression device at issue was coded as E0675, which is not covered. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and accessories have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessories (E0673) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level medial branch block (MBB).
You asked the Plan to pre-approve the third level MBB. You say that the services in dispute are medically necessary. The Plan denied your request. The Plan says the service exceeds the benefit maximum.
The Plan follows Medicare rules. Medicare rules say that the need for a three of four-level procedure bilaterally will be considered under unique circumstances with sufficient documentation of medical necessity. 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 this service. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there has not been adequate information presented to approve a three-level procedure. Our physician reviewer has determined that there are no unique circumstances or sufficient documentation for the medical necessity of a three-level procedure. 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 third level MBB have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level medial branch block (MBB).
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
October 30, 2020.
You asked the Plan to pay for these services. You say that the enrollee should not be responsible for this bill as
she told the Plan she was moving. The Plan denied your request. The Plan says the enrollee did not have prior
authorization of 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 October 30, 2020.
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 is medically necessary. 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. The record shows that insulin is taken twice per day. 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 pay for physician services provided to the enrollee out of network on
February 11, 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 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 physician services provided to the enrollee out of
network on February 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond September 15, 2021.
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 continued services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on August 16, 2021. The physical therapy and occupational therapy notes state that he needs modified assist to sit up and maximal assist to lie down. He is able to sit in a wheelchair for about four and a half hours per day. He has no skilled nursing or skilled therapy needs and does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. 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 continued skilled nursing facility (SNF) services beyond September 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided to the enrollee on February 2, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was seen by a psychologist who does not meet the criteria for treatment in Colorado, as the psychologist is licensed in Ohio. The enrollee underwent supportive and cognitive psychotherapy. 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 pay for psychotherapy services (90837) provided to the enrollee on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and spinal stenosis. The record indicates that imaging has demonstrated moderate spinal stenosis at L2-L3, the level requested for treatment. The record indicates that the enrollee has a body mass index of 43. The elements of the coverage criteria are not satisfied. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and diagnostic imaging provided by a participating provider on April 9, 2021.
You asked the Plan to waive the copayment for a specialist office visit and diagnostic imaging. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayments have been 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 $45 copayment for physician/practitioner services/specialist and a $50 copayment for outpatient diagnostic tests/outpatient diagnostic tests.
You have been asked to pay a $45 copayment for a specialist office visit and $48.06 which is less than your copayment amount of $50 for a diagnostic imaging. The total amount you are being asked to pay is $98.06 ($45 + $40.06 = $98.06). A specialist office visit falls within the physician/practitioner services/specialist benefit category. Diagnostic imaging falls within the outpatient diagnostic tests/outpatient diagnostic tests 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 a specialist office visit and diagnostic imaging provided by a participating provider on April 9, 2021.