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

We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on March 4, 2021.

You asked the Plan to pay for a fluid circulating cold pad with pump. You say that you were able to reduce pain medication and healing time after your total knee replacement using the item at issue. The Plan denied your request. The Plan says rules for payment for the requested item have not been met.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump is not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Specifically, the item at issue is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on March 4, 2021.
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 April 9, 2021.

You asked the Plan to pay for this service. 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 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 April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the right leg without contrast.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a recent six-week trial of doctor-prescribed treatment.
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 MRI is not medically reasonable or necessary. Our physician reviewer found firstly, the right knee injury did not result in a fracture and no decreased range of motion was noted on physical exam. There is no red flag noted. Secondly, the most recent injury was apparently to the calf and ankle. No detailed physical exam or plain x-rays of this area were in the records. Absent a documented physical or x-ray finding constituting a red flag the medical necessity of MRI of the right knee, calf and ankle has not been established in the records provided. 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 MRI of the right leg without contrast
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99350) provided on February 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services (99350) provided on February 25, 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 laboratory services rendered by the out-of-network (OON) provider on March 3, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 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 laboratory services rendered by the out-of-network (OON) provider on March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The Plan denied your request. The Plan says the requested Hyalgan is not medically necessary.

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 Hyalgan. Our reviewer says that the requested Hyalgan is not medically necessary. Our physician reviewer found the enrollee has been treated with cortisone injections. The medical records did not indicate member's failure to respond to or inability to tolerate conservative treatments of NSAIDs or physical therapy. The documentation does not support that the Hyalgan is medically reasonable or necessary for the enrollee. The documentation does not support that Hyalgan is safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, sleep chair
(E1399).

You asked the Plan to pre-approve the sleep chair. You say that you have had back pain since a car accident
that happened in March 2018 and had previous back surgery. The Plan denied your request. The Plan says this
item is for comfort and/or convenience and is not covered.

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 miscellaneous durable medical equipment, sleep chair
(E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says electro-acupuncture devices used for stimulation of auricular acupuncture points
are non-covered.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is
not a covered Medicare benefit.
The requested device is considered an auricular stimulator and therefore not covered by Medicare or the plan.
Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met.
Therefore, we decided that the Plan does not have to pre-approve a DyAnsys stimulator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits for observation (D9430 x2) provided from January 19, 2021, through May 11, 2021.

You asked the Plan to pay for office visits for observation. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for office visits for observation (D9430 x2) provided from January 19, 2021, through May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
March 16, 2021, through March 17, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says an inpatient stay was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the record did not show that at the time of inpatient admission the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency
department and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from March 16, 2021, through
March 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you are requesting more visits so she can continue to improve and finish her therapy. You say that you sent all the information that was requested, and the visits were still denied. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has plateaued with therapy. Our reviewer says that further skilled therapy is not likely to achieve any significant improvement in the patient's symptoms or functional status. Our reviewer says that further utilization of the home exercise program is appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth consult (99443) provided March 25, 2021.

You asked the Plan to waive the copayment for the telehealth consult. You say that there was an error and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $10 copayment for Primary Care consultations and visits. 

You have been asked to pay a $10 copayment for the telehealth consult. The telehealth consult falls within the Primary Care consultations and 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 telehealth consult (99443) provided March 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on April 14, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $110 copayment for each Medicare-covered emergency room visit. 

You have been asked to pay a $110 copayment for the Medicare-covered emergency room visit provided. 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 room visit (99285) provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 24, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you should not be penalized and stuck with a bill because you did not want to go to the hospital in a pandemic when it was not needed and without your family to accompany you. The Plan denied your request. The Plan says ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD)
you had at an ambulatory surgical center on April 14, 2021.

You asked the Plan to waive the copayment for the EGD. You say that this was something you needed and you
don't understand why it was denied. The Plan denied your request. The Plan says this claim wasn't denied,
rather, just a copayment was assessed. The Plan says that 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 $300
copayment for ambulatory surgical center services.

You have been asked to pay a $300 copayment for the EGD. The EGD falls within the ambulatory surgical
center 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
esophagogastroduodenoscopy (EGD) you had at an ambulatory surgical center on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70492) provided on
January 15, 2021.

You asked the Plan to pay for a CT scan. You say that this should be covered. The Plan denied your request.
The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine
whether payment is due and the amount of payment.

We find that CPT code 70492 is not supported in the medical record. Specifically, medical records have not
been submitted that document that this service was performed. Based on this information, we decided that
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have
to pay for a computed tomography (CT) scan (70492) provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prodigy no coding test strips provided on May 24, 2021.
You asked the Plan to pay for prodigy no coding test strips. The Plan denied your request. The Plan says this was purchased without a prescription from your doctor, therefore the drug is considered to be over-the-counter (OTC) and not covered by your Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and prodigy no coding test strips is an OTC item. Therefore, we decided that the Plan does not have to pay for prodigy no coding test strips provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on May 5, 2021.
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections (Q5103) provided March 4,
2021, to April 21, 2021.

You asked the Plan to waive the copayment for the injections. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost sharing was 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 20%
coinsurance for Part B drugs.

You have been asked to pay 20% of the total allowed amount for both injections ($64.98 and $68.89). the
injections fall within the Part B drugs benefit category. Additionally, you have been asked to pay $1.00 for self-administered
drugs that are not covered under the Part B medical benefit. 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 injections (Q5103) provided March 4, 2021, to April 21, 2021.

Benefits for the injections may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living facility services provided on February 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the assisted living facility services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 the assisted living facility services provided on February 18, 2021 by an out-of-network (OON) provider.