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

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI).

You asked the Plan to pre-approve MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 MRI. Our reviewer says that the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of a left knee total arthroplasty who is having left knee pain. There is concern for loosening of the prothesis based on examination findings and plain radiologic imaging. Based on the medical records provided the documentation indicates that computed tomography scanning of the left knee is the appropriate imaging modality as the next step in the evaluation of the enrollee's left knee symptoms as opposed to magnetic resonance (MRI) scanning. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3320), a crown (D2740), a core
buildup (D2950), periodontal scaling and root planning (D4342 x2), an upper partial denture (D5211), and a
lower partial denture (D5212) provided on May 11, 2021.
You asked the Plan to pay for endodontic therapy, a crown, a core buildup, periodontal scaling and root
planning, an upper partial denture, and a lower partial denture. You say that you disagree with the Plan's denial
The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit
maximum had already been met.
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 endodontic therapy, a crown, a core buildup, periodontal scaling and root planning, an upper
partial denture, and a lower partial denture have not been met. Specifically, the record shows that you had
exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay for
endodontic therapy (D3320), a crown (D2740), a core buildup (D2950), periodontal scaling and root planning
(D4342 x2), an upper partial denture (D5211), and a lower partial denture (D5212) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided June
28, 2021.
You asked the Plan to pay for the eye refraction. You say that you would like the service covered. The Plan
denied your request. The Plan says this service is not covered under your benefit unless rendered by one of the
Plan's routine vision care provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when performed during a routine exam by one of the Plan's vision
vendor's routine vision care provider.
We looked at the file and the Plan's rules. In this case the eye refraction was performed as part of a medical eye
exam and was performed by a non-participating provider. Based on this information, we decided that the Plan's
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to
pay for the determination of refractive state (92015) provided June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, telemedicine service,
(99308-95) provided on April 28, 2021.
You asked the Plan to pay for the SNF telehealth visit. You say that the service was medically necessary. The
Plan denied your request. The Plan says the service is limited to once every 30 days. The Plan also says that the
frequency limit has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that subsequent nursing facility care services are
limited to one telehealth visit every 30 days.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF care have not been met. Specifically, the file shows that the Plan paid for the same service
from the provider in this case less than 30 days before. Therefore, we decided that the Plan does not have to
pay for the subsequent nursing facility care, telemedicine service, (99308-95) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional transportation trips (W6110).

You asked the Plan to pre-approve the additional transportation trips. You say that you need more routine transportation. The Plan denied your request. The Plan says the request exceeds the Plan's maximum frequency for this service.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the additional transportation trips (W6110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care and inpatient care you received from May 18, 2021, to May 25, 2021.
You asked the Plan to waive the copayments. The Plan denied your request. The Plan says you are responsible for the copayments.
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 per visit for emergency care. Your contract also says that you must pay a $250 copayment per day for days 1-6 per inpatient admission.
Review of the file shows that you were provided emergency care and inpatient care from May 18, 2021, to May 25, 2021. You have been asked to pay a $90 copayment for the emergency care. You have also been asked to pay a $250 copayment per day for days 1-6 of the inpatient admission, totaling $1,500. 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 emergency care and inpatient care you received from May 18, 2021, to May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table.

You asked the Plan to pre-approve the table. 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. 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 an inversion table.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on June 23, 2021.

You asked the Plan to reimburse you for hearing aids. You say that you called the Plan to get assistance in filing a reimbursement form and you were told the hearing aids were covered. The Plan denied your request. The Plan says you did not utilize your hearing aid benefit and did not use a network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The records show that you did not receive hearing aids from the Plan's specific required provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy.
You asked the Plan to pre-approve the colonoscopy. You say that the colonoscopy is being ordered due to a new change in bowel movements over the age of 50, which is considered an alarm symptom of colon cancer. You also say that the enrollee is having abdominal pain, and you believe it is within the enrollee's best interest to rule out colon cancer with a colonoscopy. The Plan denied your request. The Plan says this 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 colonoscopy. Our reviewer says that the available records do not support that medical necessity criteria nor eviCore evidence-based COLON-7 guidelines are met in the appellant's case for colonoscopy as requested. Our physician reviewer found no alarm signs or symptoms were described, for example, the enrollee did not report rectal bleeding, significant involuntary weight loss, evidence of obstruction, nor was heme positive stool or iron deficiency anemia identified.
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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-precision abutment attachments (D6052) and bone grafts (D6104).

You asked the Plan to pre-approve the semi-precision abutment attachments (D6052) and bone grafts (D6104). The Plan denied your request. The Plan says the services are not covered benefits.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the semi-precision abutment attachments (D6052) and bone grafts (D6104).

Please note, code D6052 is not a current code. Code D6052 has been replaced with codes D6191 and D6192. Contact the Plan regarding submitting an updated request for that service.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.

You asked the Plan to pre-approve CT scan. You say that you are following a new groundglass nodule seen on previous imaging. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no recommendation for routine imaging of the pelvis.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for this CT scan. Our physician reviewer found as new groundglass opacities were seen in March 2021 that would allow CT of the chest as follow-up. CT of the abdomen/pelvis is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on September 11, 2020.
You asked the Plan to pay for the rotary wing air transport and mileage. You say that coverage was approved per the letter from the Plan dated January 20, 2021, but no payment has been received. The Plan denied your request. The Plan says these are non-covered charges.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 rotary wing air transport and mileage. Our reviewer says that the air ambulance service was not medically necessary. Our physician reviewer found the documentation does not support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. Our reviewer found that the documentation does not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Our physician reviewer also found that the documentation does not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee, as she could have been treated medically at a lower level of care until surgery was available as she was hemodynamically stable and did not require urgent surgery. 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 rotary wing air transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) and polycarbonate lenses (V2784) provided on June 15, 2021.
You asked the Plan to pay for an eye refraction and polycarbonate lenses. You say that you called your vision provider and they provided you with a list of contracted providers you could go to. You also say you were told your glasses would be covered up to $200. The Plan denied your request. The Plan says you obtained impact-resistant polycarbonate lenses, which are outside your benefit limitation. The Plan also says that in order for the eye refraction to be paid, an exam must be filed with the code.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services for single vision, lined bifocal or trifocal lenses only, at no cost. The Plan contract says that you receive one routine eye exam with refraction, every year, and a $200 allowance, every 24 months, towards the purchase of frames. We looked at the file and the Plan's rules. The records show that you purchased polycarbonate lenses and they are not a covered benefit. You received a 20% savings for this enhancement which brings your total cost to $52. The records also show that the eye refraction was billed without an eye exam code and therefore, not a covered benefit unless it is submitted with an eye exam code. Based on this information, we decided that the Plan's rules for coverage of an eye refraction and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) and polycarbonate lenses (V2784) provided on June 15, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on April 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no authorization on file.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these OON items. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on April 7, 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 Corona Virus testing (U0002) and ultrasonic guidance for needle placement (76942) provided on May 26, 2021.
You asked the Plan to pay for the Corona Virus testing and ultrasonic guidance for needle placement. You say that you would like reconsideration because these codes are distinct and separately payable. The Plan denied your request. The Plan says the billed codes are mutually exclusive to codes that have already been processed and paid.
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 U0002 and 76942 are not supported in the record. Specifically, HCPCs code U0002 does not meet criteria for billing or reimbursement consideration. The claim has been billed with CPT code 87635 for Corona Virus testing. CPT code 87635 has been paid by the Plan.
It is not appropriate to bill the HCPCs code and CPT code for Corona Virus testing on the same claim. Additionally, CPT code 76942 does not meet criteria for billing or reimbursement consideration. CPT code 76942 has a bundled relationship with column I code 76882. CPT code 76942 has not been billed with a modifier to indicate that this service was separate and distinct. Based on this information, we decided that Medicare rules for coverage of the Corona Virus testing and ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pay for the Corona Virus testing (U0002) and ultrasonic guidance for needle placement (76942) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological examination (S0621), lenses (V2100),
and eyeglass frames (V2025) provided on June 20, 2021.
You asked the Plan to pay for an ophthalmological examination, lenses, and eyeglass frames. You say that the
requested items/services were an urgent need. The Plan denied your request. The Plan says rules for payment
have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when obtained from a provider in the Plan's routine vision provider
network.
We looked at the file and the Plan's rules. The items/services at issue were obtained from an out-of-network
provider. Based on this information, we decided that the Plan's rules for coverage of an ophthalmological
examination, lenses, and eyeglass frames have not been met. Therefore, we decided that the Plan does not have
to pay for an ophthalmological examination (S0621), lenses (V2100), and eyeglass frames (V2025) provided
on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says this is not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet injections are covered for the indications
established in the applicable LCD.
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 facet joint injections. Our reviewer says
that the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer
found that there is no documentation as to why radiofrequency ablation is not medically appropriate for the enrollee. The requested facet joint injections are not medically reasonable or necessary according to the coverage criteria established in the LCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.