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

We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) scan of upper,
middle, and lower spine, out of network.
You asked the Plan to pre-approve out-of-network providers. You say that this imaging is medically necessary.
The Plan denied your request. The Plan says this imaging can be provided 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 must 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
a Magnetic Resonance Imaging (MRI) scan of upper, middle, and lower spine, out of network.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic hearing exam (92557) provided on September 15, 2021.
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that you feel you shouldn't have to pay for the services as you were only sent down the hall. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $25 copayment for Hearing services.
You have been asked to pay a $25 copayment for a diagnostic hearing exam. The plan says that even though the services were a part of the office visit, you will still be assessed a separate copayment for audiology services. 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 diagnostic hearing exam (92557) provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy (NPWT) pump.
You asked the Plan to pre-approve continued NPWT pump use. You say that continued use of the NPWT pump is medically necessary. The Plan denied your request. The Plan says the denial of authorization for continued use of this device is correct.
The Plan follows Medicare rules. Medicare rules say that continued use of a negative pressure wound therapy (NPWT) will be denied if any measure degree of wound healing has failed to occur over a month. 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 continued NPWT pump use. Our reviewer says that the enrollee does not meet the Medicare criteria for continued use of a negative pressure wound therapy pump. Our physician reviewer found the records indicate the enrollee's wound has not decreased in size or shown signs of improvement over the past month. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued NPWT pump use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy (NPWT) pump.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95861, 95939, 95938, 95868,
95927, 95940, A4215, A4556) provided on July 29, 2021.
You asked the Plan to pay for neuromonitoring services. You say that this is supported in the records. The Plan
denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which
another place of service (POS) code already exists, providers should use the POS code for that entity. However,
if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are
to use the Mobile Unit POS code 15.
We looked at the file and Medicare rules. The services at issue were billed with Mobile Unit POS code 15, but
the records show that these services were provided in service of an entity for which another POS code exists.
Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not
been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95861,
95939, 95938, 95868, 95927, 95940, A4215, A4556) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the visit (99214) provided on September 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter". We find that CPT code 99214 is not supported in the medical record. Specifically, the records show that the visit was billed with an emergency room place of service (POS 23). It is inappropriate to code 99214 for an emergency department visit. 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 the visit (99214) provided on September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Extra ambulance attendant, ground (A0424), Ambulance and Other Transport Services and Supplies (A0999), Ambulance (als or bls) oxygen and oxygen supplies, life
sustaining situation (A0422), Ambulance waiting time (A0420), Bls routine disposable supplies (A0382) provided on April 5, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says based on Medicare guidelines, the A0422 - Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation, A0420 - Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments, A0382 - BLS routine disposable supplies, A0999 x 4 - Unlisted ambulance service and A0424 - Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged) (non-transport ambulance services) you and/or your provider is/are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment. The rules say that payment under the fee schedule for ambulance services includes a base rate payment plus a separate payment for mileage. Ambulance suppliers must accept the Medicare allowed charges as payment in full and may not bill or collect from the beneficiary any amount other than the unmet cost-sharing.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of for Extra ambulance attendant, ground (A0424), Ambulance and Other Transport Services and Supplies (A0999), Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422), Ambulance waiting time (A0420), Bls routine disposable supplies (A0382) have not been met. Therefore, we decided that the Plan does not have to pay for Extra ambulance attendant, ground (A0424), Ambulance and Other Transport Services and Supplies (A0999), Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422), Ambulance waiting time (A0420), Bls routine disposable supplies (A0382) provided on April 5, 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 LTACH services are medically
necessary. The Plan denied your request. The Plan says 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 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 waive the copayment for a specialist office visit (99213) provided on August 4, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as no services were provided while you were there and you did not need to be there. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $35 copayment for Physician/Practitioner services, including doctor's office visits. You have been asked to pay a $35 copayment for a specialist office visit. The record indicates that there was an echocardiogram performed on August 4, 2021. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits 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 (99213) provided on August 4, 2021.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD).
He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on February 22, 2021.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.
Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on February 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiogram (TTE) testing.
You asked the Plan to pre-approve TTE test. You say that this testing is medically necessary. The Plan denied
your request. The Plan says the denial of authorization for this service is correct, because this test 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 TTE test. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found documentation does not point to a change in status that would support repeat TTE testing at this
time. The last study in 2020 was normal, with no intervening change in clinical status or new signs, symptoms,
or physical findings.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have
to pre-approve transthoracic echocardiogram (TTE) testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the lungs
for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be evidence of a 30 pack-year smoking history.
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 the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee does not
have the required smoking volume to qualify for low dose computed tomography. There is also a history of
pulmonary nodules on prior CT in 2019. The plan has indicated that a conventional scan would be approved if
requested.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve low dose computed tomography (CT) scan of the lungs for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an Eculizumab injection.
You asked the Plan to pre-approve an Eculizumab injection. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says that this treatment is experimental for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an Eculizumab injection. Our reviewer
says that an Eculizumab injection is medically necessary. Our physician reviewer found Eculizumab is FDA
approved for the treatment of atypical hemolytic uremic syndrome to inhibit complement-mediated thrombotic
microangiopathy. Given the limited treatment options and that the data from small observational studies show
significant response rates, the use of Eculizumab is reasonable and medically necessary and likely to be safe
and effective in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Eculizumab injection have been met. Therefore, we decided that the Plan has
to pre-approve an Eculizumab injection.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care.
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 while the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
There is not a reasonable expectation that this patient 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
October 20, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you feel that you should only have
one copayment since you were seen previously for the same condition. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for each emergency care visit.
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit
provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (80061, 80053) provided on September 27, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $15 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $15 copayment for laboratory services. Laboratory services 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 laboratory services (80061, 80053) provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), and endodontic therapy (D3320) provided on August 5, 2021, and September 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the first intraoral periapical x-ray, pulp vitality tests, and endodontic therapy. You say that you do not agree with the payment of $218.00 for your reimbursement because you originally paid $580.00. The Plan denied your request. The Plan says reimbursement for services was issued accordingly.

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, you are responsible for a 20% coinsurance for OON covered supplemental preventive dental services and a 50% coinsurance for Medicare-covered dental services and supplemental comprehensive dental services received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), and endodontic therapy (D3320) provided on August 5, 2021, and September 9, 2021 by an out-of-network (OON) provider.