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

We decided that the Plan does not have to waive the copayments for surgical destruction of benign lesions
(17110) and removal of impacted cerumen (69210) performed on February 10 to May 20, 2021.

You asked the Plan to waive the copayments for surgical destruction of benign lesions and removal of impacted
cerumen. You say that you had no idea you would be charged for the services at issue as an outpatient hospital
surgery and would not have had the procedures done. The Plan denied your request. The Plan says the correct
copayments were applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copayment for Medicare-covered outpatient hospital surgery services.

You have been asked to pay $400, or a $100 copayment for each of 4 dates of service, for surgical destruction
of benign lesions and removal of impacted cerumen. Surgical destruction of benign lesions and removal of
impacted cerumen fall within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" 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 surgical destruction of benign lesions (17110) and removal of impacted cerumen (69210) performed on
February 10 to May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid check (92592) provided on April 9, 2021.
You asked the Plan to pay for a hearing aid check. You say that you lost your hearing in your left ear forty
years ago and you have limited hearing in your right ear. You also say that it is necessary to check your right
ear and your hearing aids every six months. The Plan denied your request. The Plan says the service is
statutorily non-covered and/or is not a Medicare benefit.
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. Medicare rules
specifically state this is a non-covered service.
We looked at the file and the Plan's rules. The service at issue is not covered benefits of Medicare or the Plan.
Based on this information, we decided that the Plan's rules for coverage of a hearing aid check have not been
met. Therefore, we decided that the Plan does not have to pay for a hearing aid check (92592) provided on
April 9, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary as they would provide no advantage to continuing short-term additional care at the current facility. 

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 has to waive the copayment for the urgent care visit to obtain a COVID-19 test
provided on December 22, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says that the correct copayment has applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Per Medicare, Medicare Advantage Plans can't charge copayments, deductibles,
or coinsurance for clinical lab tests to detect or diagnose COVID-19. In this case, the medical records clearly
show the enrollee was at this provider strictly for a COVID-19 test. No other services were performed during
this visit. Therefore, we decided that the Plan has to waive the copayment for the urgent care visit to obtain a
COVID-19 test provided on December 22, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical magnetic resonance imaging (MRI)

You asked the Plan to pre-approve a cervical MRI (72156). You say that you do not believe the results from the previous MRI was properly reviewed. The Plan denied your request. The Plan says repeat imaging is not supported without results of prior imaging showing a clear reason for it.

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 magnetic resonance (eg, proton)
imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical (72156). Our reviewer says that the service is not medically necessary. Our physician reviewer found the information provided for review did not contain the results of the previously approved service. Nor was any clinical explanation provided for review as to why the member would need to undergo a repeat MRI of the cervical spine (particularly in the absence of any results from the previously authorized service). In the absence of such information it cannot be concluded that performance of another MRI would be reasonable and necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical (72156) have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical magnetic resonance imaging (MRI)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of fascia (11043) provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the debridement of fascia. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not received for services rendered by an OON 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 debridement of fascia (11043) provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT Scan of the head (70450) provided on May 21, 2021.
You asked the Plan to pay for the CT Scan of the head. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an Explanation of Benefits (EOB) from the members primary insurance carrier is needed before this claim can be considered.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance.
This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the CT Scan of the head until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the CT Scan of the head (70450) provided on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0651) and pneumatic appliance (E0667) provided on January 11, 2021.

You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for mild peripheral edema and bilateral foot pain.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0651) and pneumatic appliance (E0667) provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
You asked the Plan to pre-approve the MRI. You say that you recently had an MRI performed on your vertebrae in June 2021, but you believe that the results were not properly reviewed and request a new MRI. The Plan denied your request. The Plan says the requested service is not medically necessary as the medical records show the same study or a test like it was already completed for the enrollee. Repeat imaging is not supported without results of prior imaging.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the records indicates that the enrollee had an MRI in June 2021 but disagrees with its reading. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
Appeal type: Surgery
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled RN to come to the enrollee's home.

You asked the Plan to pre-approve the skilled RN services. You say that the enrollee needs RN services for insulin and diabetes management, as well as monitoring his feet for any further deterioration of his toes, and to check for wounds. The Plan denied your request. The Plan says the enrollee no longer has a need for skilled nursing services.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, 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 the skilled RN services. Our reviewer says that ongoing home health RN services are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Our reviewer found that the enrollee is noted to be able to self-administer his insulin; it is just that the enrollee forgets to do so. Requiring reminders to take medications is not a skilled nursing need. Reminders can be accomplished via family, friends, neighbors or electronic devices. Our physician reviewer also found that the enrollee's care need is custodial. 

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 skilled RN services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a skilled RN to come to the enrollee's home.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June
11, 2021, and June 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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
services 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 the services provided by an out-of-network provider on June 11,
2021, and June 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99214) provided on April 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 office or other outpatient visit (99214) provided on April 21, 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 services provided by an out-of-network provider on
August 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.
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
services 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 the services provided by an out-of-network provider on August
19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
You asked the Plan to preapprove the continuous glucose monitor. You say that you require the device because
it helps keep your blood glucose numbers in check. The Plan denied your request. The Plan says you do not
meet coverage criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
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 assess 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 or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to
preapprove a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles provided on April 6, 2021.
You asked the Plan to pay for the services provided. You say that the services are payable as in-network. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code A4215 is Needle, sterile, any size, each. We find that CPT code A4215 was billed with a place of service of 13, an assisted living facility. Payment for medical and surgical supplies are packaged into payment with the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the sterile needles provided on April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 27, 2021.

You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, PT services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on April 27, 2021.